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name:FInnerty, Molly

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Impact of a mental health based primary care program on emergency department visits and inpatient stays

Breslau, Joshua; Leckman-Westin, Emily; Han, Bing; Pritam, Riti; Guarasi, Diana; Horvitz-Lennon, Marcela; Scharf, Deborah M; Finnerty, Molly T; Yu, Hao
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.
PMCID:5936476
PMID: 29475010
ISSN: 1873-7714
CID: 2963922

Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid

Leckman-Westin, Emily; Finnerty, Molly; Scholle, Sarah Hudson; Pritam, Riti; Layman, Deborah; Kealey, Edith; Byron, Sepheen; Morden, Emily; Bilder, Scott; Neese-Todd, Sheree; Horwitz, Sarah; Hoagwood, Kimberly; Crystal, Stephen
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.
PMID: 29485947
ISSN: 2376-1032
CID: 2965512

Impact of a Mental Health Based Primary Care Program on Quality of Physical Health Care

Breslau, Joshua; Leckman-Westin, Emily; Yu, Hao; Han, Bing; Pritam, Riti; Guarasi, Diana; Horvitz-Lennon, Marcela; Scharf, Deborah M; Pincus, Harold A; Finnerty, Molly T
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.
PMID: 28884234
ISSN: 1573-3289
CID: 2984692

Integrating physical health: What were the costs to behavioral health care clinics?

Connor, Kathryn L; Breslau, Joshua; Finnerty, Molly T; Leckman-Westin, Emily; Pritam, Riti; Yu, Hao
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.
PMCID:5869100
PMID: 29316449
ISSN: 1873-7714
CID: 3064202

"Zero Suicide" - A model for reducing suicide in United States behavioral healthcare

Labouliere, Christa D; Vasan, Prabu; Kramer, Anni; Brown, Greg; Green, Kelly; Rahman, Mahfuza; Kammer, Jamie; Finnerty, Molly; Stanley, Barbara
Suicide is a serious public health concern in the US, especially for those served in outpatient behavioral health. Over the past decade, there has been a dramatic increase in US suicide rates, and a significant proportion of those dying by or attempting suicide were treated in outpatient behavioral healthcare within the prior year. In response, the US Action Alliance released the National Strategy for Suicide Prevention in 2012, a key tenet of which is the "Zero Suicide" (ZS) model. ZS provides resources for administrators and providers to create a systematic approach to quality improvement for suicide prevention in healthcare systems via seven essential elements (Lead, Train, Identify, Engage, Treat, Transition, Improve). In this paper, we describe the ZS model, as well as our operationalization of the model in an NIMH-funded study in ~170 free-standing New York State outpatient behavioral health clinics, serving >80,000 patients. This study is the largest implementation and evaluation of the ZS approach ever conducted in outpatient behavioral health. Evaluation of ZS implementation in "real-world" clinical settings will provide crucial insight regarding broader dissemination and inform how to best adopt empirically-supported care for suicidal patients in outpatient behavioral health, thereby reducing tragic and preventable loss of life.
PMCID:6022755
PMID: 29970972
ISSN: 1892-9842
CID: 3185832

Enrollment of Specialty Mental Health Clinics in a State Medicaid Program to Promote General Medical Services

Breslau, Joshua; Yu, Hao; Horvitz-Lennon, Marcela; Leckman-Westin, Emily; Scharf, Deborah M; Connor, Kathryn L; Finnerty, Molly T
OBJECTIVE:To promote integrated general medical care for individuals with serious mental illness, the New York State Office of Mental Health (OMH) established regulations allowing specialty mental health clinics to provide Medicaid-reimbursable health monitoring (HM) and health physicals (HP). This study examined clinics' enrollment in this program to understand its potential to reach individuals with serious mental illness. METHODS:Information on enrollment and characteristics of clinics (N=500) was obtained from OMH administrative databases. Clinic enrollment in the HM/HP program was examined for the program's first five years (2010-2015). Logistic regression models accounting for the clustering of multiple clinics within agencies were used to examine characteristics associated with enrollment. RESULTS:A total of 291 of 500 (58%) licensed clinics in New York State in 2015 enrolled in the HM/HP program, potentially reaching 62% of all Medicaid enrollees with serious mental illness seen in specialty mental health clinics in the state. State-operated clinics were required to participate, and had 91% enrollment. Over half of hospital-affiliated and freestanding mental health clinics elected to enroll (53% and 54%, respectively). In adjusted models, enrollment was higher among freestanding clinics compared with hospital-affiliated clinics, higher in larger than smaller clinics, and higher in county-operated than in private nonprofit clinics. CONCLUSIONS:The high level of enrollment in the HM/HP program indicates strong interest among mental health clinics in providing general medical care services. However, supplemental policies may be needed to extend the program to areas of the mental health system where barriers to general medical care services are highest.
PMCID:5205557
PMID: 27524372
ISSN: 1557-9700
CID: 3097912

Access to Psychosocial Services Prior to Starting Antipsychotic Treatment Among Medicaid-Insured Youth

Finnerty, Molly; Neese-Todd, Sheree; Pritam, Riti; Leckman-Westin, Emily; Bilder, Scott; Byron, Sepheen C; Hudson Scholle, Sarah; Crystal, Stephen; Olfson, Mark
OBJECTIVE: To examine rates and predictors of receiving a psychosocial service before initiating antipsychotic treatment among young people in the Medicaid program. METHOD: A retrospective new-user cohort study of 8 state Medicaid programs focused on children and adolescents 0 to 20 years, initiating antipsychotic treatment (N = 24,372). The proportion receiving a psychosocial service in the 3 months before initiating antipsychotic treatment was calculated and stratified by socio-demographic and diagnostic characteristics arranged in 9 hierarchical groups, as follows: developmental, psychotic/bipolar, disruptive, attention-deficit/hyperactivity, obsessive-compulsive, stress, major depressive, anxiety, and other disorders. RESULTS: Less than one-half of youth received a psychosocial service before initiating antipsychotic treatment (48.8%). Compared to younger adolescents (12-17 years) initiating antipsychotic treatment (51.5%), corresponding younger children (0-5 years; 39.2%) and older adolescents (18-20 years; 40.1%), but not older children (6-11 years; 51.5%), were significantly less likely to have received a psychosocial service. In relation to youth diagnosed with psychotic or bipolar disorder (52.7%), those diagnosed with attention-deficit/hyperactivity (43.3%), developmental (41.4%), depressive (46.5%), or anxiety (35.6%) disorder were significantly less likely to have received a psychosocial service during the 3 months before antipsychotic initiation. By contrast, youth diagnosed with stress disorders (61.2%) were significantly more likely than those diagnosed with psychotic or bipolar disorders (52.7%) to have received a psychosocial service before starting an antipsychotic. CONCLUSION: A majority of Medicaid-insured youth initiating antipsychotic treatment have not received a psychosocial service in the preceding 3 months. This service pattern highlights a critical gap in access to psychosocial services.
PMID: 26703912
ISSN: 1527-5418
CID: 1884352

Use of Pooled State Administrative Data for Mental Health Services Research

Hoagwood, Kimberly Eaton; Essock, Susan; Morrissey, Joseph; Libby, Anne; Donahue, Sheila; Druss, Benjamin; Finnerty, Molly; Frisman, Linda; Narasimhan, Meera; Stein, Bradley D; Wisdom, Jennifer; Zerzan, Judy
State systems are a rich, albeit challenging, laboratory for policy-relevant services research studies. State mental health authorities routinely devote resources to collect data for state planning and reporting purposes. However, these data are rarely used in cross-state comparisons to inform state or federal policy development. In 2008, in response to key recommendations from the National Institute of Mental Health (NIMH) Advisory Council's "The Road Ahead: Research Partnership to Transform Services," ( http://www.nimh.nih.gov/about/advisory-boards-and-groups/namhc/reports/road-ahead .pdf ), NIMH issued a request for applications (RFA) to support studies on the impact of state policy changes on access, cost, quality and outcomes of care for individuals with mental disorders. The purpose of the RFA was to bridge the divide between research and policy by encouraging research that used state administrative data across states, and to address significant state-defined health policy initiatives. Five projects involving eight states were selected through peer review for funding. Projects began in 2009 and were funded for 3 years. This report provides a brief description of the five projects, followed by an analysis of the impact, challenges, and lessons learned from these policy-partnered studies. We conclude by offering suggestions on ways to use state administrative data for informing state health policies, which is especially timely given national and state changes in the structure and financing of healthcare.
PMCID:4500680
PMID: 25578511
ISSN: 0894-587x
CID: 1435992

Multifamily Group Psychoeducation in New York State: Implementation and Fidelity Outcomes

Kealey, Edith M; Leckman-Westin, Emily; Jewell, Thomas C; Finnerty, Molly T
OBJECTIVE: The study examined implementation outcomes from a large state initiative to support dissemination of multifamily group (MFG) psychoeducation in outpatient mental health settings. METHODS: Thirty-one sites participated in the project. Baseline training in the MFG model was followed by monthly expert consultation delivered in either a group (16 sites) or individual format (15 sites). Research staff assessed fidelity to the MFG model by telephone at baseline and 12, 18, and 24 months and documented time to completion of three key milestones: holding a family joining session, a family educational workshop, and an MFG meeting. RESULTS: Intent-to-train analyses found that 12 sites (39%) achieved high fidelity to the MFG model, and 20 (65%) achieved moderate or high fidelity. Mean scores on the Family Psychoeducation Fidelity Assessment Scale increased over time. Twenty-five sites (81%) conducted at least one joining session, and 20 (65%) conducted at least one MFG. Mean+/-SD time from baseline to the first group was 11.75+/-4.78 months. Programs that held the first joining session within four to 12 months after training were significantly more likely than programs that did not to conduct a group (p<.05). No significant differences were found by consultation format. CONCLUSIONS: Implementation of moderate- to high-fidelity MFG programs in routine outpatient mental health settings is feasible. Sites that moved very quickly or very slowly in early implementation stages were less likely to be successful in conducting an MFG. More research on the efficiency and effectiveness of consultation formats is needed to guide future implementation efforts.
PMID: 26278227
ISSN: 1557-9700
CID: 1732102

Clinicians' Perceptions of Challenges and Strategies of Transition from Assertive Community Treatment to Less Intensive Services

Finnerty, Molly T; Manuel, Jennifer I; Tochterman, Ana Z; Stellato, Candice; Fraser, Linda H; Reber, Cecily A S; Reddy, Hima B; Miracle, Angela D
The study aimed to identify clinical strategies and challenges around transition from Assertive Community Treatment (ACT) to less intensive services. Six focus groups were conducted with ACT team leaders (n = 49). Themes were grouped under four intervention-focused domains: (1) client/clinical, (2) family and natural supports, (3) ACT staff and team, and (4) public mental health system. Barriers to transition included beliefs that clients and families would not want to terminate services (due to loss of relationships, fear of failure, preference for ACT model), clinical concerns that transition would not be successful (due to limited client skills, relapse without ACT support), systems challenges (clinic waiting lists, transportation barriers, eligibility restrictions, stigma against ACT clients), and staff ambivalence (loss of relationship with client, impact on caseload). Strategies to support transition included building skills for transition, engaging supports, celebrating success, enhanced coordination with new providers, and integrating and structuring transition in ACT routines.
PMCID:4289526
PMID: 24526472
ISSN: 0010-3853
CID: 905202