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Barsky BA, Shields MC. Psychiatric Restraint Use as Carceral State Practice. Psychiatr Serv 2024; 75:307. [PMID: 38557135 DOI: 10.1176/appi.ps.24075006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Benjamin A Barsky
- George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis (Shields); Edmond & Lily Safra Center for Ethics, Harvard University, and Harvard Law School Project on Disability, Harvard Law School, Cambridge, Massachusetts (Barsky)
| | - Morgan C Shields
- George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis (Shields); Edmond & Lily Safra Center for Ethics, Harvard University, and Harvard Law School Project on Disability, Harvard Law School, Cambridge, Massachusetts (Barsky)
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Shields MC, Kantawala Z, Raghavan R. Why Patient-Centered Built Environment Standards Matter More Than Numbers of Beds in Inpatient Psychiatry. AMA J Ethics 2024; 26:E237-247. [PMID: 38446729 DOI: 10.1001/amajethics.2024.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
This article canvasses extant literature about values, evidence, and standards for inpatient psychiatry units' design. It then analyzes apparent trade-offs between quality of care and access to care using empirical and ethical lenses. From this analysis, the authors conclude that standards for the built environment of inpatient psychiatric care should align with patient-centeredness, even if a downstream consequence of implementing new patient-centered designs is a reduction in beds, although this secondary outcome is unlikely.
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Affiliation(s)
- Morgan C Shields
- Assistant professor in the Brown School of Social Work at Washington University in St Louis
| | - Zohra Kantawala
- Current MPH student in the Brown School of Social Work at Washington University in St Louis
| | - Ramesh Raghavan
- Professor in the Silver School of Social Work at New York University in New York City
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Xu KY, Gold JA, Szlyk HS, Rolin SA, Shields MC. Mental Illness and Violence Among People Experiencing Homelessness: An Evidence-Based Review. Mo Med 2024; 121:14-20. [PMID: 38404439 PMCID: PMC10887459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Division of Addiction Science, Prevention, and Treatment, Washington University, and in the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Jessica A Gold
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Hannah S Szlyk
- Health and Behavior Research Center, Division of Addiction Science, Prevention, and Treatment, Washington University, and in the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie A Rolin
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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Hollander MAG, Patton A, Shields MC. Changes in institution for mental diseases (IMD) ownership status and insurance acceptance over time. Health Aff Sch 2024; 2:qxad089. [PMID: 38234578 PMCID: PMC10790904 DOI: 10.1093/haschl/qxad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/11/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
State Medicaid programs are prohibited from using federal dollars to pay institutions for mental diseases (IMDs)-freestanding psychiatric facilities with more than 16 beds. Increasingly, regulatory mechanisms have made payment of treatment in these settings substantially more feasible. This study evaluates if changing financial incentives are associated with increases in for-profit ownership among IMD facilities relative to non-IMD facilities, as well as greater increases in Medicaid acceptance among for-profit IMD facilities relative to for-profit non-IMD facilities. We used data from the 2014-2020 National Mental Health Services Surveys and examined 11 945 facility-years. Relative to non-IMDs, the increase in for-profit ownership among IMDs was 6.6 percentage points greater. The largest proportional change in Medicaid acceptance occurred among for-profit IMD facilities relative to for-profit non-IMDs (18.5 percentage points). Existing research is mixed on the quality of inpatient and residential psychiatric care provided in for-profit vs nonprofit and public facilities, as well as in IMD relative to non-IMD facilities. As payment policy increasingly incentivizes for-profit facilities to enter the psychiatric care space, we should be mindful of the impact of these decisions on patient safety.
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Affiliation(s)
- Mara A G Hollander
- Department of Public Health Sciences, University of North Carolina at Charlotte,Charlotte, NC 28223, United States
| | - Alexandra Patton
- Department of Public Health Sciences, University of North Carolina at Charlotte,Charlotte, NC 28223, United States
| | - Morgan C Shields
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO 63130, United States
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Ochman FJ, Shields MC. COVID-19 Mitigation Activities in Inpatient Psychiatry Were Associated With Patient-Reported Institutional Betrayal, Changes in Trust, and Fear of Getting Sick. Inquiry 2024; 61:469580241237689. [PMID: 38462912 DOI: 10.1177/00469580241237689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Institutional betrayal occurs when the institutions that people depend on fail to protect them from harm, which was exemplified by a failure to manage COVID-19 risks. Inpatient psychiatry provides a rich context for which to understand the effects of institutional betrayal, and this is amplified in the context of the COVID-19 pandemic. Using a retrospective cohort design, we administered an online survey to former patients (n = 172) of inpatient psychiatry hospitalized at the height of the COVID-19 pandemic (March 2020 to February 2021) to understand the relationship between facilities' use of COVID-19 mitigation activities (ie, offering or requiring face masks, keeping patients and staff 6 feet apart, access to hand sanitizer, use of telemedicine for clinical consults, and routine cleanliness of the unit) and former patients' reports of institutional betrayal, changes in their trust in mental healthcare providers, fear of getting sick, and having contracted or witnessed someone else contract COVID-19. The quantity of COVID-19 mitigation activities was monotonically negatively associated with the probability of reporting any betrayal, the probability of reduced trust in mental healthcare providers, and the probability of being afraid of getting sick always or most of the time while hospitalized. COVID-19 mitigation activities either directly affected these psychological outcomes, or facilities that engaged in robust mitigation had greater cultures of safety and care quality. Additional qualitative work is needed to understand these mechanisms.
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Affiliation(s)
| | - Morgan C Shields
- Washington University in St. Louis, Brown School, St. Louis, MO, USA
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Andraka-Christou B, Golan OK, Totaram R, Shields MC, Cortelyou K, Atkins DN, Lambie GW, Mazurenko O. Operationalizing person-centered care in residential substance use disorder treatment. J Addict Dis 2023:1-16. [PMID: 37602811 DOI: 10.1080/10550887.2023.2247810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Person-centered care (PCC) is an ethical imperative with eight domains, but operation of some PCC domains in substance use disorder (SUD) treatment has been underexplored. OBJECTIVE We sought to identify strategies for operationalizing eight PCC domains in SUD treatment facilities and themes across these strategies. METHODS We recruited 36 clients and staff from a large publicly funded behavioral health system for individual, semi-structured qualitative interviews. Interviews explored preferences and care experiences for each PCC domain. We analyzed data using iterative categorization, identifying specific operationalization strategies and themes across operationalization strategies within each domain. RESULTS PCC operationalization themes for residential SUD treatment included addressing social vulnerability of clients (e.g., through assistance with housing and navigation of criminal/legal systems), involving peer support specialists (e.g., to provide emotional support and aid transition out of care), supporting the client's family throughout treatment (e.g., providing progress updates; increasing visitation opportunities in residential treatment), and facilitating patient choice within each domain (e.g., treatment type; housing type; roommate preferences in residential treatment.). DISCUSSION & CONCLUSION Some PCC operationalization strategies are unique to SUD treatment. Several PCC operationalization strategies applied to multiple domains, suggesting conceptual overlap between domains.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management & Informatics, University of Central Florida, Orlando, FL, USA
- Department of Internal Medicine, University of Central Florida, Orlando, FL, USA
| | - Olivia K Golan
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Rachel Totaram
- School of Global Health Management & Informatics, University of Central Florida, Orlando, FL, USA
| | - Morgan C Shields
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Kendall Cortelyou
- School of Global Health Management & Informatics, University of Central Florida, Orlando, FL, USA
| | - Danielle N Atkins
- Askew School of Public Administration, Florida State University, Tallahassee, FL, USA
| | - Glenn W Lambie
- Department of Counselor Education & School Psychology, University of Central Florida, Orlando, FL, USA
| | - Olena Mazurenko
- Department of Health Policy & Management, Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
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Andraka-Christou B, Atkins DN, Shields MC, Golan OK, Totaram R, Cortelyou K, Lambie GW, Mazurenko O. Key person-centered care domains for residential substance use disorder treatment facilities: former clients' perspectives. Subst Abuse Treat Prev Policy 2023; 18:45. [PMID: 37461114 DOI: 10.1186/s13011-023-00554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/12/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND While person-centered care (PCC) includes multiple domains, residential substance use disorder (SUD) treatment clients may value certain domains over others. We sought to identify the PCC domains most valued by former residential SUD treatment clients. We also sought to explore conceptual distinctions between potential theoretical PCC subdomains. METHODS We distributed an online survey via social media to a national convenience sample of former residential SUD treatment clients. Respondents were presented with ten PCC domains in an online survey: (a) access to evidence-based care; (b) integration of care; (c) diversity/respect for other cultures; (d) individualization of care; (e) emotional support; (f) family involvement in treatment; (g) transitional services; (h) aftercare; (i) physical comfort; and (j) information provision. Respondents were asked to select up to two domains they deemed most important to their residential SUD treatment experience. We used descriptive statistics to identify response frequencies and logistic regression to predict relationships between selected domains and respondents' race, gender, relationship status, parenting status, and housing stability. RESULTS Our final sample included 435 former residential SUD treatment clients. Diversity and respect for different cultures was the most frequently selected domain (29%), followed by integration of care (26%), emotional support (26%), and individualization of care (26%). Provision of information was the least frequently chosen domain (3%). Race and ethnicity were not predictive of selecting respect for diversity. Also, parental status, relationship status and gender were not predictive of selecting family integration. Employment and housing status were not predictive of selecting transitional services. CONCLUSIONS While residential SUD treatment facilities should seek to implement PCC across all domains, our results suggest facilities should prioritize (a) operationalizing diversity, (b) integration of care, and (c) emotional support. Significant heterogeneity exists regarding PCC domains deemed most important to clients. PCC domains valued by clients cannot be easily predicted based on client demographics.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management & Informatics, University of Central Florida, 525 W Livingston Street, Suite 401, Orlando, FL, 32801, USA.
- Department of Internal Medicine, University of Central Florida, Orlando, FL, USA.
| | - Danielle N Atkins
- Askew School of Public Administration, Florida State University, Tallahassee, FL, USA
| | - Morgan C Shields
- Brown School, Washington University in St. Louis, St. Louis, United States
| | - Olivia K Golan
- School of Public Health, Georgia State University, Atlanta, Georgia
| | - Rachel Totaram
- School of Global Health Management & Informatics, University of Central Florida, 525 W Livingston Street, Suite 401, Orlando, FL, 32801, USA
| | - Kendall Cortelyou
- School of Global Health Management & Informatics, University of Central Florida, 525 W Livingston Street, Suite 401, Orlando, FL, 32801, USA
| | - Glenn W Lambie
- Department of Counselor Education & School Psychology, University of Central Florida, Orlando, FL, USA
| | - Olena Mazurenko
- Department of Health Policy & Management, Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
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Shields MC, Hollander MA. Complaints, Restraint, and Seclusion in Massachusetts Inpatient Psychiatric Facilities, 2008-2018. J Patient Exp 2023; 10:23743735231179072. [PMID: 37323757 PMCID: PMC10265359 DOI: 10.1177/23743735231179072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
There has been limited research on the quality of inpatient psychiatry, yet policies to expand access have increased, such as the use of Medicaid Section 1115 waivers for treatment in "Institutions for Mental Disease" (IMD). Using data from public records requests, we evaluated complaints, restraint, and seclusion from inpatient psychiatric facilities in Massachusetts occurring from 2008 to 2018, and compared differences in the rates of these events by IMD status. There were 17,962 total complaints, with 48.9% related to safety and 19.9% related to abuse (sexual, physical, verbal), and 92,670 episodes of restraint and seclusion. On average, for every 30 census days in a given facility, restraint, and seclusion occurred 7.47 and 1.81 times, respectively, and a complaint was filed 0.94 times. IMDs had 47.8%, 68.3%, 276.9%, 284.8%, 183.6%, and 236.1% greater rates of restraint, seclusion, overall complaints, substantiated complaints, safety-related complaints, and abuse-related complaints, respectively, compared to non-IMDs. This is the first known study to describe complaints from United States inpatient psychiatric facilities. Policies should strengthen the implementation of patients' rights and patient-centeredness, as well as external critical-incident-reporting systems.
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Affiliation(s)
| | - Mara A.G. Hollander
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
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O'Brien PL, Stewart MT, Shields MC, White M, Dubenitz J, Dey J, Mulvaney-Day N. Residential treatment and medication treatment for opioid use disorder: The role of state Medicaid innovations in advancing the field. Drug Alcohol Depend Rep 2022; 4:100087. [PMID: 36157615 PMCID: PMC9495301 DOI: 10.1016/j.dadr.2022.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Mortality due to opioid use continues to increase; effective strategies to improve access to treatment for opioid use disorder (OUD) are needed. While OUD medications exist, they are used infrequently and often not available in residential addiction treatment settings. CMS provides expanded opportunities for Medicaid reimbursement of treatment in residential facilities and requires states that request Medicaid SUD Waivers to provide a full continuum of care including medication treatment. The objective of this study was to assess how states facilitate access to OUD medications in residential settings and whether Medicaid requirements play a role. METHODS Using a legal mapping framework, across the 50 states and DC, we abstracted data from state regulations in 2019 - 2020 and Medicaid Section 1115(a) demonstration applications. We examined the temporal relationship between state regulations regarding medication-assisted treatment for OUD in residential settings and Section 1115(a) demonstrations. RESULTS We identified variation in regulations regarding medication treatment for OUD in residential settings and possible spillover effects of the CMS requirements for Medicaid SUD Waivers. In 18 states with relevant regulations, regulatory approaches include identifying opioid medication treatment as a right, requiring access to OUD medication treatment, and establishing other requirements. 25 of 30 states with approved Section 1115(a) demonstrations included explicit requirements for OUD medication treatment access. Four states updated OUD medication treatment regulations for residential treatment settings within a year of applying for a Section 1115(a) demonstration. CONCLUSIONS State regulations and Medicaid program requirements are policy levers to facilitate OUD medication treatment access.
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Affiliation(s)
| | - Maureen T. Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South St, Waltham, MA, United States
| | - Morgan C. Shields
- Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA; Washington University in St. Louis, Brown School, 1 Brookings Dr, St. Louis, MO, United States (Present address)
| | - Mackenzie White
- IBM Watson Health, 75 Binney St, Cambridge, MA, United States
| | - Joel Dubenitz
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Washington, DC, United States
| | - Judith Dey
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Washington, DC, United States
| | - Norah Mulvaney-Day
- IBM Watson Health, 75 Binney St, Cambridge, MA, United States; Dept. of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA (Present address)
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Shields MC, Beaulieu ND, Lu S, Busch AB, Cutler DM, Chien AT. Increases in Inpatient Psychiatry Beds Operated by Systems, For-Profits, and Chains, 2010-2016. Psychiatr Serv 2022; 73:561-564. [PMID: 34433287 DOI: 10.1176/appi.ps.202100182] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study explored trends in the quantity of inpatient psychiatry beds and in facility characteristics. METHODS Using the National Bureau of Economic Research's Health Systems and Provider Database, the authors examined changes in the number of psychiatric facilities and beds, focusing on system ownership, profit status, facility type (general acute care versus freestanding), and affiliation with psychiatric hospital chains from 2010 to 2016. RESULTS The number of psychiatric beds was relatively unchanged from 2010 (N=112,182 beds) to 2016 (N=111,184). However, the number of beds operated by systems increased by 39.8% (N=15,803); for-profits, by 56.9% (N=8,572); and chains, by 16.7% (N=6,256). Net increases in beds were primarily concentrated in for-profit freestanding psychiatric hospitals. In 2016, most for-profit beds were part of chains (70.2%) and systems (61.3%). CONCLUSIONS Inpatient psychiatry has shifted toward increased ownership by systems, for-profits, and chains. Payers and policy makers should safeguard against profiteering, and future research should investigate the implications of these trends on quality of care.
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Affiliation(s)
- Morgan C Shields
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Nancy D Beaulieu
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Sifan Lu
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Alisa B Busch
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - David M Cutler
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Alyna T Chien
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
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Shields MC, Trinh NHT, Borba CPC, Chen R, Reddy AK, Singer SJ. Former Inpatient Psychiatric Patients' Past Experiences With Traditional Frontline Staff and Their Thoughts on the Benefits of Peers as Part of Frontline Staff. J Psychosoc Nurs Ment Health Serv 2022; 60:15-22. [PMID: 34590985 PMCID: PMC10182870 DOI: 10.3928/02793695-20210916-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Little is known about how integrating peers into frontline staff might improve the quality of inpatient psychiatric care. In the current study, we interviewed 18 former adult patients of inpatient psychiatric facilities using semi-structured interviews. We first asked about positive and negative past experiences with traditional staff. We then asked participants to share their opinions on the potential benefits of peers as part of frontline staff. We identified themes through a joint inductive and deductive approach. Participants reported past positive experiences with traditional staff as being (a) personable and caring, (b) validating feelings and experiences, (c) de-escalating, and (d) providing agency. Past negative experiences included (a) not sharing information, (b) being inattentive, (c) not providing agency, (d) being dehumanizing/disrespectful, (e) incompetency, (f) escalating situations, and (g) being apathetic. Participants believed that peers as part of frontline staff could champion emotional needs in humanizing and nonjudgmental ways, help navigate the system, and disrupt power imbalances between staff and patients. Further research is needed to understand financial, organizational, and cultural barriers to integrating peers into frontline staff. [Journal of Psychosocial Nursing and Mental Health Services, 60(3), 15-22.].
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Shields MC, Beidas RS. The Need to Prioritize Patient-Centered Care in Inpatient Psychiatry as a Matter of Social Justice. JAMA Health Forum 2022; 3:e214461. [PMID: 36218823 PMCID: PMC10105342 DOI: 10.1001/jamahealthforum.2021.4461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Morgan C Shields
- Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Rinad S Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Shields MC, Horgan CM, Ritter GA, Busch AB. Use of Electronic Health Information Technology in a National Sample of Hospitals That Provide Specialty Substance Use Care. Psychiatr Serv 2021; 72:1370-1376. [PMID: 33853380 PMCID: PMC8517030 DOI: 10.1176/appi.ps.202000816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Most U.S. acute care hospitals have adopted basic electronic health record (EHR) functionality and health information exchange (HIE) (84% and 88%, respectively, in 2017). This study examined whether rates of EHR and HIE adoption by hospital-based substance use disorder programs are lower than rates by acute care hospitals. METHODS Data from the 2017 National Survey on Substance Abuse Treatment Services were analyzed to examine adoption of basic EHR functionality (i.e., assessment, progress monitoring, discharge, labs, and prescription dispensing) and use of HIE by hospital-based programs. Analyses used weighted multivariable models of EHR and HIE outcomes, adjusted for nonresponse. RESULTS Of 894 hospital-based substance use disorder programs with EHR information, two-thirds (N=606, 68%) reported use of basic EHR functionality. Psychiatric hospitals were less likely than acute care hospitals to have adopted EHR (odds ratio [OR]=0.49, 95% confidence interval [CI]=0.35-0.71). Compared with nonprofit hospitals, for-profit (OR=0.23, 95% CI=0.16-0.35) and government-owned (OR=0.52, 95% CI=0.33-0.83) hospitals were less likely to use basic EHR functionality. Hospital-based programs providing medications for alcohol or opioid use disorders were more likely than those not providing such medications to use basic EHR (OR=1.95, 95% CI=1.31-2.90). Of 839 hospitals with information on HIE use, 598 (71%) reported using electronic HIE. Adoption of basic EHR functionality was the strongest predictor of HIE use (OR=4.73, 95% CI=3.29-6.79). CONCLUSIONS Hospital-based substance use disorder programs trail behind U.S. acute care hospitals in adoption of basic EHR and electronic HIE. Findings raise concerns about missed opportunities to improve hospital-based substance use disorder care quality and performance measurement.
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Affiliation(s)
- Morgan C Shields
- Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Shields); Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Horgan, Ritter); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Harvard University, Boston (Busch)
| | - Constance M Horgan
- Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Shields); Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Horgan, Ritter); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Harvard University, Boston (Busch)
| | - Grant A Ritter
- Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Shields); Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Horgan, Ritter); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Harvard University, Boston (Busch)
| | - Alisa B Busch
- Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Shields); Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Horgan, Ritter); McLean Hospital, Belmont, Massachusetts, and Department of Health Care Policy, Harvard Medical School, Harvard University, Boston (Busch)
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Affiliation(s)
- Morgan C Shields
- Center for Mental Health, Department of Psychiatry(Shields, Marcus), Leonard Davis Institute of Health Economics (Shields, Marcus, Chatterjee), School of Social Policy and Practice (Marcus), and Department of Medicine (Chatterjee).,University of Pennsylvania, Philadelphia; Center for Mental Health and Addiction Policy, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (Hollander)
| | - A G Hollander
- Center for Mental Health, Department of Psychiatry(Shields, Marcus), Leonard Davis Institute of Health Economics (Shields, Marcus, Chatterjee), School of Social Policy and Practice (Marcus), and Department of Medicine (Chatterjee).,University of Pennsylvania, Philadelphia; Center for Mental Health and Addiction Policy, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (Hollander)
| | - Steven C Marcus
- Center for Mental Health, Department of Psychiatry(Shields, Marcus), Leonard Davis Institute of Health Economics (Shields, Marcus, Chatterjee), School of Social Policy and Practice (Marcus), and Department of Medicine (Chatterjee).,University of Pennsylvania, Philadelphia; Center for Mental Health and Addiction Policy, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (Hollander)
| | - Paula Chatterjee
- Center for Mental Health, Department of Psychiatry(Shields, Marcus), Leonard Davis Institute of Health Economics (Shields, Marcus, Chatterjee), School of Social Policy and Practice (Marcus), and Department of Medicine (Chatterjee).,University of Pennsylvania, Philadelphia; Center for Mental Health and Addiction Policy, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (Hollander)
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Abstract
OBJECTIVE The author examined patient demographic, clinical, payment, and geographic factors associated with admission to low-safety inpatient psychiatric facilities. METHODS Massachusetts all-payer 2017 discharge data (N=39,128 psychiatric patients) were linked to facility-level indicators of safety (N=38 facilities). A composite of safety was created by averaging standardized measures of restraint and seclusion as well as 5-year averages of overall, substantiated, and abuse-related (i.e., verbal, physical, or sexual) complaints per 1,000 discharges (α=0.73). This composite informed quintile groups of safety performance. A series of multinomial regression models were fit, with payment and geography added separately. RESULTS Notable factors independently associated with admission to low-safety facilities were belonging to a racial or ethnic minority group compared with being a White patient (for non-Hispanic Black, relative risk ratio [RRR]=1.71, p<0.01; for non-Hispanic Asian, RRR=5.60, p<0.01; for non-Hispanic "other" race, RRR=2.17, p<0.01; and for Hispanic-Latinx, RRR=1.29, p<0.01) and not having private insurance (for self-pay or uninsured, RRR=2.40, p<0.01; for Medicaid, RRR=1.80, p<0.01; and for Medicare, RRR=1.31, p<0.01). CONCLUSIONS To the best of the author's knowledge, this is the first study to examine differences in admission to low-safety inpatient psychiatric facilities. Even after accounting for potential clinical, geographic, and insurance mediators of structural racism, stark racial and ethnic inequities were found in admission to low-safety inpatient psychiatric facilities. In addition to addressing safety performance, policy makers should invest in gaining a better understanding of how differences in community-based referrals, mode of transport (e.g., police or self), and deliberate or unintentional steering and selection affect admissions and outcomes.
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Affiliation(s)
- Morgan C Shields
- Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Shields MC. Effects of the CMS' Public Reporting Program for Inpatient Psychiatric Facilities on Targeted and Nontargeted Safety: Differences Between For-Profits and Nonprofits. Med Care Res Rev 2021; 79:233-243. [PMID: 33709840 DOI: 10.1177/1077558721998924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The Centers for Medicare and Medicaid Services implemented the Inpatient Psychiatric Facility Quality Reporting Program in 2012, which publicly reports facilities' performance on restraint and seclusion (R-S) measures. Using data from Massachusetts, we examined whether nonprofits and for-profits responded differently to the program on targeted indicators, and if the program had a differential spillover effect on nontargeted indicators of quality by ownership. Episodes of R-S (targeted), complaints (nontargeted), and discharges were obtained for 2008-2017 through public records requests to the Commonwealth of Massachusetts. Using difference-in-differences estimators, we found no differential changes in R-S between for-profits and nonprofits. However, for-profits had larger increases in overall complaints, safety-related complaints, abuse-related complaints, and R-S-related complaints compared with nonprofits. This is the first study to examine the effects of a national public reporting program among psychiatric facilities on nontargeted measures. Researchers and policymakers should further scrutinize intended and unintended consequences of performance-reporting programs.
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Shields MC, Ritter G, Busch AB. Electronic Health Information Exchange At Discharge From Inpatient Psychiatric Care In Acute Care Hospitals. Health Aff (Millwood) 2020; 39:958-967. [PMID: 32479237 DOI: 10.1377/hlthaff.2019.00985] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To address the complex health care needs of patients with mental illness-who commonly have co-occurring medical conditions and substance use disorders-it is critically important for providers to use electronic health records (EHRs) for health information exchange (HIE) when patients are transferred from inpatient psychiatric units in acute care hospitals. Efficient and timely HIE is necessary to ensure that patients receive adequate and informed follow-up care. This study examined the percentage of inpatient psychiatric units that reported using EHRs for HIE at transfers of care and hospital characteristics associated with that use. We linked national data from the Inpatient Psychiatric Facility Quality Reporting Program of the Centers for Medicare and Medicaid Services, the American Hospital Association Annual Survey, and state mental health privacy laws. In 2016 the use of electronic HIE upon transfer from psychiatric units lagged behind the corresponding overall use rates from acute care hospitals (56.3 percent versus 88 percent), with wide variation across states. Hospital size and accountable care organization participation were associated with electronic HIE, but a state's having mental health privacy laws more stringent than the Health Insurance Portability and Accountability Act did not. Given these results, policy efforts to incentivize the use of electronic HIE in psychiatric settings should be strengthened.
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Affiliation(s)
- Morgan C Shields
- Morgan C. Shields is a PhD candidate and NIAAA fellow at the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, in Waltham, Massachusetts, and a research assistant in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Grant Ritter
- Grant Ritter is an associate research professor at the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University
| | - Alisa B Busch
- Alisa B. Busch is an associate professor of psychiatry and health care policy at McLean Hospital and the Department of Health Care Policy, Harvard Medical School. She is also the chief medical information officer at McLean Hospital
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18
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Abstract
Behavioral health care has been slow to take up robust efforts to improve patient safety. This lag is especially apparent in inpatient psychiatry, where there is risk for physical and psychological harm. Recent investigative journalism has provoked public concern about instances of alleged abuse, negligence, understaffing, sexual assault, inappropriate medication use, patient self-harm, poor sanitation, and inappropriate restraint and seclusion. However, empirical evidence describing the scope of unsafe experiences is limited. While evidence-based inpatient psychiatry requires care to be trauma-informed, market failures and a lack of payment alignment with patient-centered care leave patients vulnerable to harm. Existing regulatory mechanisms attempt to provide accountability; however, these mechanisms are imperfect. Furthermore, research is sparse. Few health services researchers study inpatient psychiatry, the issue has not been a priority among research funders, and data on inpatient psychiatry is excluded from national surveys of quality. Several policy levers could begin to address these deficiencies. These include aligning incentives with patient-centered care, building trauma-informed care into accreditation and monitoring, conducting trend analyses of critical incidents, and improving research capacity.
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Affiliation(s)
- Morgan C Shields
- Morgan C. Shields ( ) is a PhD student and NIAAA fellow at the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, in Waltham, Massachusetts
| | - Maureen T Stewart
- Maureen T. Stewart is a scientist at the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University
| | - Kathleen R Delaney
- Kathleen R. Delaney is a professor in the Department of Community, Systems, and Mental Health Nursing, College of Nursing, Rush University, in Chicago, Illinois
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Shields MC, Akobirshoev I, Dembo RS, Mitra M. Self-Injurious Behavior Among Adults With ASD: Hospitalizations, Length of Stay, and Costs of Resources to Deliver Care. Psychiatr Serv 2019; 70:457-464. [PMID: 30841844 DOI: 10.1176/appi.ps.201800318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Research on hospitalizations related to self-injurious behavior and ideation among adults with autism spectrum disorder (ASD) is limited. This study compared admissions, average length of stay, and costs of resources to deliver care for such hospitalizations between adults with and without ASD. METHODS The 2014 Healthcare Cost and Utilization Project National Inpatient Sample was used to compare 5,341 discharge records for adults with ASD and 16,023 records for adults without ASD, matched on age and gender in a 1:3 ratio. Hierarchical logistic and linear regressions accounted for clustering by hospital. Covariates included gender, race-ethnicity, age, region, comorbidities, number of procedures, and insurance. RESULTS Among hospitalized adults, those with ASD were twice as likely as those without ASD to have a hospitalization related to self-injurious behavior and ideation. Among hospital stays for self-injurious behavior and ideation, adults with ASD had average lengths of stay that were 2.14 days longer (95% confidence interval [CI]=1.20-3.08) compared with adults without ASD. Among adults with a hospitalization related to self-injurious behavior and ideation, unadjusted average costs for those with ASD were 36.8% higher than for adults without ASD. After the analysis accounted for covariates and length of stay, adults with ASD still had 7.48% (95% CI=1.05%-14.32%) higher costs. CONCLUSIONS Adults with ASD were twice as likely as adults without ASD to have a hospitalization related to self-injurious behavior and ideation. Among adults with such a hospitalization, those with ASD had longer stays and, even after the analysis accounted for length of stay, higher costs.
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Affiliation(s)
- Morgan C Shields
- Lurie Institute for Disability Policy (Shields, Akobirshoev, Dembo, Mitra) and Institute for Behavioral Health (Shields), Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Ilhom Akobirshoev
- Lurie Institute for Disability Policy (Shields, Akobirshoev, Dembo, Mitra) and Institute for Behavioral Health (Shields), Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Robert S Dembo
- Lurie Institute for Disability Policy (Shields, Akobirshoev, Dembo, Mitra) and Institute for Behavioral Health (Shields), Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Monika Mitra
- Lurie Institute for Disability Policy (Shields, Akobirshoev, Dembo, Mitra) and Institute for Behavioral Health (Shields), Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
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20
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Shields MC, Singer J, Rosenthal M, Sato L, Keohane C, Janes M, Boulanger J, Martins N, Rabson B. Patient Engagement Activities and Patient Experience: Are Patients With a History of Depression the Canary in the Coal Mine? Med Care Res Rev 2019; 78:251-259. [PMID: 31117918 DOI: 10.1177/1077558719850705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is known about the effectiveness of primary care practices' efforts to engage patients in their health and health care. We examine the association between patient engagement efforts and patients' experiences of care. We found no association between an unweighted count of patient engagement activities and patient experience. Compared with the bottom quartile of practices, however, the top quartile had better performance on patient experience domains of communication, front-office staff, and organizational access (out of nine domains). Furthermore, patients reporting a diagnosis of depression have higher ratings across five domains of patient experience when in practices with higher levels of patient engagement activities measured using an unweighted scale. Future research is needed to understand how the benefits of patient engagement activities can accrue to more patient subgroups. These promising results suggest that payers and policy makers should continue to support implementation and benchmarking of patient engagement efforts across practices.
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Affiliation(s)
| | - Janice Singer
- The Massachusetts Health Quality Partners, Watertown, MA, USA
| | | | - Luke Sato
- Risk Management Foundation of the Harvard Medical Institutions Incorporated (CRICO/RMF), Boston, MA, USA
| | - Carol Keohane
- Risk Management Foundation of the Harvard Medical Institutions Incorporated (CRICO/RMF), Boston, MA, USA
| | - Margaret Janes
- Risk Management Foundation of the Harvard Medical Institutions Incorporated (CRICO/RMF), Boston, MA, USA
| | - Jason Boulanger
- Risk Management Foundation of the Harvard Medical Institutions Incorporated (CRICO/RMF), Boston, MA, USA
| | - Natalya Martins
- The Massachusetts Health Quality Partners, Watertown, MA, USA
| | - Barbra Rabson
- The Massachusetts Health Quality Partners, Watertown, MA, USA
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21
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Shields MC, Reneau H, Albert SM, Siegel L, Trinh NH. Harms to Consumers of Inpatient Psychiatric Facilities in the United States: An Analysis of News Articles. Issues Ment Health Nurs 2018; 39:757-763. [PMID: 29847200 DOI: 10.1080/01612840.2018.1451579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Inpatient psychiatric facilities in the United States lack systematic regulation and monitoring of a variety of patient safety concerns. We conducted a qualitative analysis of 61 news articles to identify common causes and types of harms within inpatient psychiatric facilities, with a focus on physical harm. The news articles reported on patient self-harm, patient-patient violence, and violence between patients and staff, noting that youth, older adults, and veterans were especially vulnerable. Harms occurred throughout the care continuum - at admission, during the inpatient stay, and at discharge - and retaliation towards whistleblowers deterred facility accountability. We recommend 1) addressing staffing shortages, 2) instituting systematic monitoring of critical incidents and the experiences of consumers and staff, 3) improving both inpatient safety and post-discharge community supports, and 4) continued journalistic coverage of harms within inpatient psychiatric facilities.
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Affiliation(s)
- Morgan C Shields
- a Harvard T.H. Chan School of Public Health, Department of Health Policy and Management , Harvard University , Boston , Massachusetts , USA.,b Heller School for Social Policy and Management, Behavioral Health Institute , Brandeis University , Waltham , Massachusetts , USA
| | - Hailey Reneau
- a Harvard T.H. Chan School of Public Health, Department of Health Policy and Management , Harvard University , Boston , Massachusetts , USA
| | - Sasha M Albert
- b Heller School for Social Policy and Management, Behavioral Health Institute , Brandeis University , Waltham , Massachusetts , USA
| | - Leeann Siegel
- c Annenberg School for Communication , University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Nhi-Ha Trinh
- d Department of Psychiatry and Depression Clinical and Research Program , Massachusetts General Hospital , Boston , Massachusetts , USA
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22
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Affiliation(s)
- Morgan C Shields
- Ms. Shields is with the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, and with Brandeis University Heller School for Social Policy and Management, Waltham, Massachusetts. Dr. Borba is with Boston Medical Center, Boston. Dr. Trinh is with the Department of Psychiatry, McLean General Hospital, Boston
| | - Christina P C Borba
- Ms. Shields is with the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, and with Brandeis University Heller School for Social Policy and Management, Waltham, Massachusetts. Dr. Borba is with Boston Medical Center, Boston. Dr. Trinh is with the Department of Psychiatry, McLean General Hospital, Boston
| | - Nhi-Ha T Trinh
- Ms. Shields is with the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, and with Brandeis University Heller School for Social Policy and Management, Waltham, Massachusetts. Dr. Borba is with Boston Medical Center, Boston. Dr. Trinh is with the Department of Psychiatry, McLean General Hospital, Boston
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Shields MC, Rosenthal MB. Measuring the Quality of VA Care: In Reply. Psychiatr Serv 2017; 68:308-309. [PMID: 28240149 DOI: 10.1176/appi.ps.68305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Morgan C Shields
- The authors are with the Department of Health Policy and Management, Harvard University, Cambridge, Massachusetts (e-mail: ). Ms. Shields is also with the Heller School for Social Policy and Management, Brandeis University
| | - Meredith B Rosenthal
- The authors are with the Department of Health Policy and Management, Harvard University, Cambridge, Massachusetts (e-mail: ). Ms. Shields is also with the Heller School for Social Policy and Management, Brandeis University
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Abstract
OBJECTIVE Little is known about the quality of inpatient psychiatric care. This study examined associations between performance on seven measures of inpatient psychiatric quality and hospital ownership. METHODS The study design was a cross-sectional analysis of The Joint Commission's 2014 inpatient psychiatric hospital quality measures. The measures evaluate admission screening for violence risk, substance use, psychological trauma history, and patient strengths; use of seclusion and restraint; the practice of discharging patients on multiple antipsychotics; providing appropriate justification when patients are discharged on multiple antipsychotics; creation of continuing care plans; and transmission of care plans to the next level of care. Participants were 665 inpatient psychiatric facilities accredited by The Joint Commission. RESULTS The mean±SD percentage of patients who received admission screening was 90%±21%; multiple antipsychotics at discharge, 11%±10%; appropriate justification for use of multiple antipsychotics at discharge, 53%±33%; a continuing care plan, 88%±22%; and transmission of the care plan to the next level of care, 82%±23%. Restraint was used for .32±1.1 hours per 1,000 patient hours, and seclusion was used for .27±.8 hours per 1,000 patient hours. Hospital performance on a given measure did not necessarily predict performance on other measures. Government hospitals were low performers, and hospitals owned by the U.S. Department of Veterans Administration (VA) performed worst. CONCLUSIONS Lack of correlation across measures suggests either that inpatient psychiatric care quality is multidimensional or that it is unreliably assessed. Hospital ownership strongly predicted performance, and VA hospitals performed relatively poorly across most measures.
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Affiliation(s)
- Morgan C Shields
- The authors are with the Department of Health Policy and Management, Harvard University, Cambridge, Massachusetts (e-mail: ). Ms. Shields is also with the Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Meredith B Rosenthal
- The authors are with the Department of Health Policy and Management, Harvard University, Cambridge, Massachusetts (e-mail: ). Ms. Shields is also with the Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
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Shields MC, Matt LM, Coifman KG. Physical activity and negative emotion during peer-rejection: Evidence for emotion context sensitivity. J Health Psychol 2016; 21:2851-2862. [DOI: 10.1177/1359105315587139] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
It is well-established that physical activity is beneficial to physical and psychological health. However, how physical activity contributes to psychological health is still unclear. In this investigation, we examined the association between physical activity and negative emotions assessed in real-time during simulated-peer-rejection. Moreover, we explored mediation of this association by higher-order neurocognitive functioning and cardiovascular flexibility. Although we found no evidence for mediation, we did find that greater physical activity predicted contextually responsive negative emotion. Specifically, greater physical activity predicted generation of negative emotions in response to peer-rejection and flexible reduction of negative emotions in response to peer-acceptance.
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Abstract
In Exp. 1, a total of 144 pigs (BW, 6.68 ± 0.17 kg) were weaned at 21 d, blocked by BW, and allocated to 48 pens with 3 pigs per pen. Pens were randomly assigned to 1 of 6 dietary treatments (0, 2.5, 5, 7.5, and 10% glycerol supplemented to replace up to 10% lactose in a basal starter 1 diet containing 20% total lactose, which was fed for 2 wk), and a negative control diet with 10% lactose and 0% glycerol. A common starter diet was fed for the next 2 wk. In Exp. 2, a total of 126 pigs (BW, 6.91 ± 0.18 kg) were weaned at 21 d of age, blocked by BW, and allocated to 42 pens with 3 pigs per pen. Pigs were assigned to 1 of 6 treatments in a 2 × 3 factorial arrangement in a randomized complete block design with factors being 1) glycerol inclusion in replacement of lactose in starter 1 diets (0 or 5%) fed for 2 wk, and 2) glycerol inclusion in starter 2 diets (0, 5, or 10%) fed for 3 wk. In Exp. 1, glycerol supplementation at 10% improved (P=0.01) ADG (266 vs. 191 g/d) and G:F (871 vs. 679 g/kg) during the starter 1 period when compared with the negative control. Incremental amounts of glycerol linearly (P<0.05) increased ADG and ADFI, but did not affect G:F during starter 1. There was no effect of feeding glycerol during the starter 1 phase on subsequent performance during the starter 2 phase or overall. Serum glycerol concentrations increased linearly (P=0.003) with increasing dietary glycerol, and serum creatinine (P=0.004) and bilirubin (P=0.03) concentrations decreased with increasing glycerol. In Exp. 2, glycerol did not affect performance during starter 1, but it linearly increased (P≤0.01) ADG and ADFI during starter 2 (464, 509, and 542 and 726, 822, and 832 g/d, respectively) and overall (368, 396, and 411 and 546, 601, and 609 g/d, respectively). At the end of the study, pigs were 1.0 and 1.5 kg heavier when fed 5 and 10% glycerol, respectively (linear, P<0.01). Serum glycerol concentrations increased linearly during starter 2 (P<0.001), but were not affected during starter 1. Glycerol supplementation increased serum urea N quadratically (P<0.001) and decreased creatinine linearly (P<0.05) in the starter 2 phase. Overall, data indicate that glycerol can be added to nursery pig diets at 10%, while improving growth performance.
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Affiliation(s)
- M C Shields
- Department of Animal Science, North Carolina State University, Raleigh, 27695, USA
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27
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Nguyen VT, Ndoye A, Bassler KD, Shultz LD, Shields MC, Ruben BS, Webber RJ, Pittelkow MR, Lynch PJ, Grando SA. Classification, clinical manifestations, and immunopathological mechanisms of the epithelial variant of paraneoplastic autoimmune multiorgan syndrome: a reappraisal of paraneoplastic pemphigus. Arch Dermatol 2001; 137:193-206. [PMID: 11176692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND Recent studies suggest that paraneoplastic pemphigus (PNP) is a heterogeneous autoimmune syndrome involving several internal organs and that the pathophysiological mechanisms mediating cutaneous, mucosal, and internal lesions are not limited to autoantibodies targeting adhesion molecules. OBJECTIVE To classify the diverse mucocutaneous and respiratory presentations of PNP and characterize the effectors of humoral and cellular autoimmunity mediating epithelial tissue damage. METHODS We examined 3 patients manifesting the lichen planus pemphigoideslike subtype of PNP. A combination of standard immunohistochemical techniques, enzyme-linked immunosorbent assay with desmoglein (DSG) baculoproteins, and an immunoprecipitation assay were used to characterize effectors of humoral and cellular autoimmunity in patients with PNP and in neonatal wild-type and DSG3-knockout mice with PNP phenotype induced by passive transfer of patients' IgGs. RESULTS In addition to the known "PNP antigenic complex," epithelial targets recognized by PNP antibodies included 240-, 150-, 130-, 95-, 80-, 70-, 66-, and 40/42-kd proteins but excluded DSG1 and DSG3. In addition to skin and the epithelium lining upper digestive and respiratory tract mucosa, deposits of autoantibodies were found in kidney, urinary bladder, and smooth as well as striated muscle. Autoreactive cellular cytotoxicity was mediated by CD8(+) cytotoxic T lymphocytes, CD56(+) natural killer cells, and CD68(+) monocytes/macrophages. Inducible nitric oxide synthase was visualized both in activated effectors of cellular cytotoxicity and their targets. Keratin 14-positive basal epithelial cells sloughed from the large airways and obstructed small airways. CONCLUSIONS The paraneoplastic disease of epithelial adhesion known as PNP in fact represents only 1 manifestation of a heterogeneous autoimmune syndrome in which patients, in addition to small airway occlusion and deposition of autoantibodies in different organs, may display a spectrum of at least 5 different clinical and immunopathological mucocutaneous variants (ie, pemphiguslike, pemphigoidlike, erythema multiforme-like, graft-vs-host disease-like, and lichen planus-like). We suggest that the more encompassing term "paraneoplastic autoimmune multiorgan syndrome," or PAMS, be applied. The pathophysiological mechanisms of PAMS involve both humoral and cellular autoimmunity responses. Epithelial cell membrane antigens other than DSG1 or DSG3 are targeted by effectors of PAMS autoimmunity. Apoptosis of damaged basal cells mediates epithelial clefting, and respiratory failure results possibly from obstruction of small airways with sloughed epithelial cells.
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Affiliation(s)
- V T Nguyen
- Department of Dermatology, University of California Davis Medical Center, 4860 Y St, Sacramento, CA 95817, USA
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Shields MC. Hospital rounding program: an example. Med Group Manage J 1998; 45:10, 12, 14-6. [PMID: 10181643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- M C Shields
- Dreyer Medical Center, Aurora, IL 60506, USA
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Shields MC, Steinmetz J, Weber D. Re-engineering physical therapy. Med Group Manage J 1997; 44:8, 10, 39. [PMID: 10167632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Dowell M, Shields MC. Outcomes: some practical considerations. Med Group Manage J 1995; 42:10, 12-4, 50-1. [PMID: 10155929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Shields MC. The physician-administrator team revisited. Med Group Manage J 1994; 41:10, 110. [PMID: 10161114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Shields MC. Physician practice and feedback of information. Med Group Manage J 1994; 41:6, 8. [PMID: 10131362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Shields MC. Profitability analysis and the physician/administrator team. Med Group Manage J 1991; 38:12-3. [PMID: 10160715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Shields MC. Dealing with the era of parsimony. Med Group Manage J 1990; 37:11. [PMID: 10160597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- M C Shields
- Midwest Medical Group, Oak Brook Terrace, IL
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Abstract
An educational program for children with asthma designed to reduce emergency room (ER) use enrolled all eligible children (n = 253 primarily low-income Black) within a health maintenance organization (HMO) who had used the hospital or ER for asthma during the pre-enrollment period and randomized them into two groups. Twenty-four of the experimental group patients had 55 ER visits and 18 of the control patients had 39 ER visits during the first 12 months post-intervention. This program did not achieve its goal.
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Affiliation(s)
- M C Shields
- Department of Medicine, Michael Reese Hospital and Medical Center, Chicago, IL 60616
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Griffin KW, McNabb WL, Shields MC. Telephone instruction as an adjunct to patient education of children with asthma. J Healthc Educ Train 1988; 4:1-6. [PMID: 10293028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Anderson OW, Shields MC. Health maintenance organizations. The concept and status of Health Maintenance Organizations and competition in the United States. Tidsskr Nor Laegeforen 1986; 106:849-53. [PMID: 3738879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Anderson OW, Shields MC. Quality measurement and control in physician decision making: state of the art. Health Serv Res 1982; 17:125-55. [PMID: 7047464 PMCID: PMC1068671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The status of the concept of controlling the quality of physicians is reviewed as are studies that have been done on methods to measure and improve quality. The conclusions are dismal given the rhetoric and actions on attempts to measure and control quality of physician decision making. Massive attempts are being made, for example, mandating PSROs to monitor quality before there is a methodology. Cost and quality reviews have, at most, a marginal impact and do not deserve the expenditures to conduct them. Studies on utilization review show minimal impact on reducing utilization. Administrative reviews reduce utilization for certain specific, narrowly defined procedures such as injections. There is no operational definition of "unnecessary" utilization. The tendency is to regard the lowest levels as optimal, presumably because they result in lower expenditures. Bureaucratic reviews do not provide incentives to decision makers the way various types of HMO delivery types do from current evidence. Hence, HMOs, deductibles and coinsurance, and competition have greater promise for limiting expenditures than do utilization reviews. Quality audits are also marginally effective because of limited promise of changing provider behavior given current methods of doing so. They miss the organizational aspects in which incentives are generated. Research is needed, therefore, on alternative forms of quality and cost control such as HMOs, physician risk sharing, competitive models, and deductibles and coinsurance. Until the much needed research has been done, the amount of resources spent on review should be minimized. In the meantime, the review processes should concentrate on extreme variations of very narrowly defined criteria of proven validity while improving the review methodology by systematic research on quality monitoring.
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Patel DV, Shields MC. Intraventricular hemorrhage in pituitary apoplexy. J Comput Assist Tomogr 1979; 3:829-31. [PMID: 512115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A case of pituitary apoplexy is presented with previously unreported computed tomographic findings of intraventricular hemorrhage. Because of the successful use of new microsurgical techniques for the treatment of pituitary apoplexy even in patients with poor clinical status, it is important to differentiate the various causes of intraventricular hemorrhage by aggressive evaluation.
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Shields MC. Reducing "unnecessary" hospitalization. N Engl J Med 1973; 289:380-1. [PMID: 4718529 DOI: 10.1056/nejm197308162890727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Shields MC. Maximum Convenience in Citations. Science 1938; 88:11-2. [PMID: 17743671 DOI: 10.1126/science.88.2270.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Shields MC. A Determination of the Ratio of the Specific Heats of Hydrogen at 18° and -190°C. Proc Natl Acad Sci U S A 1917; 3:502-3. [PMID: 16576249 PMCID: PMC1091300 DOI: 10.1073/pnas.3.8.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- M C Shields
- Ryerson Physical Laboratory, University of Chicago
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