Faculty Bibliography

Providing physical health care in specialty mental health clinics is a promising approach to improving the health status of adults with serious mental illness, but most programs examined in prior studies are not financially sustainable. This study assessed the impact on quality of care of a low-cost program implemented in New York State that allowed mental health clinics to be reimbursed by Medicaid for provision of health monitoring and health physicals (HM/HP). Medicaid claims data were analyzed with generalized linear multilevel models to examine change over time in quality of physical health care associated with HM/HP services. Recipients of HM/HP services were compared to control clinic patients [Per protocol (PP)] and with non-recipients of HM/HP services from both intervention and control clinics [As-Treated (AT)]. HM/HP clinic patients, regardless of receipt of HM/HP services, were compared with control clinic patients [Intent-to-Treat (ITT)]. Analyses were conducted with adjustment for patient demographic and clinical characteristics and prior year service use. The PP and AT analyses found significant improvement in measure of blood glucose screening for patients on antipsychotic medication and HbA1C testing for patients with diabetes (AOR range 1.26-1.33) and the AT analysis found significant improvement in cholesterol screening for patients on antipsychotic medication (AOR 1.24). However, ITT analysis found no significant changes in quality of care in HM/HP clinic caseloads relative to control clinics. The low-cost HM/HP program has the potential to benefit patients who receive supported services, but its impact is limited by remaining barriers to service implementation.

BACKGROUND:The treatment of suicidal patients often suffers owing to a lack of integrated care and standardized approaches for identifying and reducing risk. The National Strategy for Suicide Prevention endorsed the Zero Suicide (ZS) model, a multi-component, system-wide approach to identify, engage, and treat suicidal patients. The ZS model is a framework for suicide prevention in healthcare systems with the aspirational goal of eliminating suicide in healthcare. While the approach is widely endorsed, it has yet to be evaluated in a systematic manner. This trial evaluates two ZS implementation strategies statewide in specialty mental health clinics. METHODS/STUDY DESIGN/UNASSIGNED:This trial is the first large-scale implementation of the ZS model in mental health clinics using the Assess, Intervene, and Monitor for Suicide Prevention (A-I-M) clinical model. Using a hybrid effectiveness-implementation type 1 design, we are testing the effectiveness of ZS implementation in 186 mental health clinics in 95 agencies in New York State. Agencies are randomly assigned to either: "Basic Implementation" (BI; a large group didactic learning collaboratives) or "Enhanced Implementation" (EI; participatory small group learning collaboratives; enhanced consultation for site champions). Primary outcomes include suicidal behaviors, hospitalizations and Emergency Department visits; implementation outcomes include protocol adoption, protocol fidelity and barriers/facilitators to implementation. DISCUSSION/CONCLUSIONS:This project has the potential to have a significant public health impact by determining the effectiveness of the ZS model in mental health clinics, a setting where suicide attempts and suicides occur at a higher rate than any other healthcare setting. It will also provide guidance on the implementation level required to achieve uptake and sustainability of ZS. TRIAL REGISTRATION/BACKGROUND:N/A.

OBJECTIVE/UNASSIGNED:This cross-sectional study examined the relationship between antipsychotic medication adherence and preventable diabetes-related hospitalizations for individuals with diabetes and schizophrenia. METHODS/UNASSIGNED:Hospitalizations related to diabetes, an ambulatory care sensitive condition, were assessed among Medicaid recipients in New York State with comorbid diabetes and schizophrenia (N=14,365) for three levels of antipsychotic medication adherence: very low to no engagement (two or fewer prescriptions or none in first 6 months), moderate to low adherence, and adherent (proportion of days covered ≥80%). RESULTS/UNASSIGNED:Rates of preventable diabetes hospitalization were highest among individuals with very low to no engagement in antipsychotic treatment (4.7%), followed by those with moderate to low adherence (3.3%). Diabetes hospitalizations among adherent individuals were comparable with those of the total diabetes population (both 2.0%). The odds of a preventable diabetes hospitalization were significantly higher among individuals with very low to no engagement in antipsychotic treatment (adjusted odds ratio [AOR]=2.42) and among those with moderate to low adherence (AOR=1.57) than among adherent individuals. Black individuals were also at increased risk of a preventable diabetes hospitalization after the analyses adjusted for antipsychotic adherence and other variables (AOR=1.38). CONCLUSIONS/UNASSIGNED:This study indicates a relationship between antipsychotic adherence and improved diabetes outcomes among individuals with schizophrenia. Engagement in mental health treatment may be a critical path toward improving health disparities for individuals with schizophrenia. Individuals with very low to no engagement were a particularly vulnerable group, and the exclusion of persons with less than two prescriptions from research and quality measures should be revisited.

To inform efforts to improve physical health care for adults with serious mental illness, this study examines predictors of provision and receipt of physical health services in freestanding mental health clinics in New York state. The number of services provided over the initial 12-months of implementation varied across clinics from 0 to 1407. Receipt of services was associated with a diagnosis of schizophrenia, frequent mental and physical health visits in the prior year, and prescription of antipsychotic medications. Additional support may also be needed to enable clinics to target patients without established patterns of frequent mental health or medical visits.

Electronic shared-decision making programs may provide an assistive technology to support physician-patient communication. This mixed methods study examined use of a web-based shared decision-making program (MyCHOIS-CommonGround) by individuals receiving specialty mental health services, and identified qualitative factors influencing adoption during the first 18 months of implementation in two Medicaid mental health clinics. T-tests and χ² analyses were conducted to assess differences in patient use between sites. Approximately 80% of patients in both clinics created a MyCHOIS-CommonGround user profile, but marked differences emerged between clinics in patients completing shared decision-making reports (79% vs. 28%, χ²₍₁₎ = 109.92, p < .01) and average number of reports (7.20 vs. 3.60, t = - 3.64, p < .01). Results suggest high penetration of computer-based programs in specialty mental health services is possible, but clinic implementation factors can influence patient use including leadership commitment, peer staff funding to support the program, and implementation strategy, most notably integration of the program within routine clinical workflow.

OBJECTIVE:/UNASSIGNED:The authors examined the impact of a Web-based shared decision-making application, MyCHOIS-CommonGround, on ongoing outpatient mental health treatment engagement (all users) and antipsychotic medication adherence (users with schizophrenia). METHODS:/UNASSIGNED:An intervention study was conducted by comparing Medicaid-enrolled MyCHOIS-CommonGround users in 12 participating mental health clinics (N=472) with propensity score-matched adults receiving services in nonparticipating clinics (N=944). Medicaid claims were used to assess ongoing treatment engagement and antipsychotic adherence (among individuals with schizophrenia) one year prior to and after entry into the cohort. Multilevel linear models were conducted to estimate the effects of the MyCHOIS-CommonGround program over time. RESULTS:/UNASSIGNED:No differences during the baseline year were found between the MyCHOIS-CommonGround group and the matched control group on demographic, diagnostic, or service use characteristics. At one-year follow-up, engagement in outpatient mental health services was significantly higher for MyCHOIS-CommonGround users than for the control group (months with a service, 8.54±.22 versus 6.95±.15; β=1.40, p<.001). Among individuals with schizophrenia, antipsychotic medication adherence was also higher during the follow-up year among MyCHOIS-CommonGround users compared with the control group (proportion of days covered by medication, .78±.04 versus .69±.03; β=.06, p<.01). CONCLUSIONS:/UNASSIGNED:These findings provide new evidence that shared decision-making tools may promote ongoing mental health treatment engagement for individuals with serious mental illness and improved antipsychotic medication adherence for those with schizophrenia.

OBJECTIVE:Integrating primary care services into specialty mental health clinics has been proposed as a method for improving health care utilization for medical conditions by adults with serious mental illness. This paper examines the impact of a mental health based primary care program on emergency department (ED) visits and hospitalizations. METHOD/METHODS:The program was implemented in seven New York City outpatient mental health clinics in two waves. Medicaid claims were used to identify patients treated in intervention clinics and a control group of patients treated in otherwise similar clinics in New York City. Impacts of the program were estimated using propensity score adjusted difference-in-differences models on a longitudinally followed cohort. RESULTS:Hospital stays for medical conditions increased significantly in intervention clinics relative to control clinics in both waves (ORs = 1.21 (Wave 1) and 1.33 (Wave 2)). ED visits for behavioral health conditions decreased significantly relative to controls in Wave 1 (OR = 0.89), but not in Wave 2. No other significant differences in utilization trends between the intervention and control clinics were found. CONCLUSION/CONCLUSIONS:Introducing primary care services into mental health clinics may increase utilization of inpatient services, perhaps due to newly identified unmet medical need in this population.

BACKGROUND:Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines. OBJECTIVES/OBJECTIVE:To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use. METHODS:Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring. RESULTS:Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening. CONCLUSIONS:While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children. DISCLOSURES/UNASSIGNED:This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.

We examine the impact of mental health based primary care on physical health treatment among community mental health center patients in New York State using propensity score adjusted difference in difference models. Outcomes are quality indicators related to outpatient medical visits, diabetes HbA1c monitoring, and metabolic monitoring of antipsychotic treatment. Results suggest the program improved metabolic monitoring for patients on antipsychotics in one of two waves, but did not impact other quality indicators. Ceiling effects may have limited program impacts. More structured clinical programs to may be required to achieve improvements in quality of physical health care for this population.

OBJECTIVE:To inform providers and policy-makers about the potential costs of providing physical health care in mental health clinics. METHODS:Cost data were collected through interviews with 22 behavioral health clinics participating in New York State Office of Mental Health's health monitoring and health physicals programs. The interview data was combined with financial reporting data provided to the state to identify per interaction costs for two levels of physical health services: health monitoring and health monitoring plus health physicals. RESULTS:This study gives detailed information on the costs of clinics' health integration programs, including per interaction costs related to direct service, charting and administration, and total care coordination. Average direct costs per client interaction were 3 times higher for health physicals than for health monitoring. CONCLUSIONS:Costs of integrating physical care services are not trivial to mental health clinics, and may pose a barrier to widespread adoption. Provision of limited health monitoring services is less expensive for clinics, but generates proportionally large non-clinical costs than health physicals. The relative health impact of this more limited approach is an important area for future study. Also, shifting reimbursement to include health care coordination time may improve program sustainability.