Psychiatric Boarding Patterns Among Publicly Insured Youths Evaluated by Mobile Crisis Teams Before and During the COVID-19 Pandemic.

Importance: Psychiatric boarding occurs when patients needing intensive psychiatric services who are already under clinical supervision experience delays in their admission to psychiatric facilities. Initial reports have suggested that the US had a psychiatric boarding crisis during the COVID-19 pandemic; however, little is known about the consequences of this crisis for publicly insured youths. Objective: To estimate pandemic-associated changes in psychiatric boarding rates and discharge modalities for people aged 4 to 20 years who accessed psychiatric emergency services (PES) through a mobile crisis team (MCT) evaluation and were covered by Medicaid or health safety net programs. Design, Setting, and Participants: This retrospective cross-sectional study used data from the MCT encounters of a multichannel PES program in Massachusetts. A total of 7625 MCT-initiated PES encounters with publicly insured youths who lived in Massachusetts between January 1, 2018, and August 31, 2021, were assessed. Main Outcomes and Measures: Encounter-level outcomes (psychiatric boarding status, repeat visits, and discharge disposition) during a prepandemic period (January 1, 2018, to March 9, 2020) were compared with outcomes during a pandemic period (March 10, 2020, to August 31, 2021). Descriptive statistics and multivariate regression analysis were used. Results: Among 7625 MCT-initiated PES encounters, the mean (SD) age of publicly insured youths was 13.6 (3.7) years; most youths identified as male (3656 [47.9%]), were of Black race (2725 [35.7%]) or Hispanic ethnicity (2708 [35.5%]), and spoke English (6941 [91.0%]). During the pandemic period, the mean monthly boarding encounter rate was 25.3 percentage points higher than the prepandemic period. After adjustment for covariates, the odds of an encounter resulting in boarding doubled during the pandemic (adjusted odds ratio [AOR], 2.03; 95% CI, 1.82-2.26; P < .001), and boarding youths were 64% less likely to be discharged to inpatient psychiatric care (AOR, 0.36; 95% CI, 0.31-0.43; P < .001). Publicly insured youths who boarded during the pandemic had significantly higher rates of 30-day readmissions (incidence rate ratio, 2.17; 95% CI, 1.88-2.50; P < .001). Boarding encounters during the pandemic were significantly less likely to end in discharge to inpatient psychiatric units (AOR, 0.36; 95% CI, 0.31-0.43; P < .001) or community-based acute treatment facilities (AOR, 0.70; 95% CI, 0.55-0.90; P = .005). Conclusions and Relevance: In this cross-sectional study, publicly insured youths were more likely to experience psychiatric boarding during the COVID-19 pandemic and, if boarding, were less likely to transfer to a 24-hour level of care. These findings suggest that psychiatric service programs for youths were not prepared to support the levels of acuity and demand that emerged from the pandemic.

Locked down or locked out? Trends in psychiatric emergency services utilization during the COVID-19 pandemic.

OBJECTIVE: To estimate changes in Boston Emergency Services Team (BEST) psychiatric emergency services (PES) encounter volume (total and by care team) and inpatient disposition during the first 8 months of the COVID-19 pandemic. METHODS: Data on 30,657 PES encounters was extracted from the four-county, BEST reporting system. The study period consisted of the first 34 weeks of 2019 and 2020. This period corresponded to the first five stages of Massachusetts's COVID-19 public health restrictions: pre-lockdown, lockdown, Phase I, II and III reopenings. Descriptive and regression analyses were performed to estimate changes in encounter volume by care team and disposition. RESULTS: Compared to the same period in 2019, covariate-adjusted, weekly PES encounters decreased by 39% (ß = -0.40, 95% Confidence Interval (CI) = [-0.51, -0.28], p < 0.00) during the lockdown. PES volume remained significantly lower during Phase I reopening compared to the previous year but returned to 2019 levels during Phase II. The covariate-adjusted proportion of weekly encounters that led to inpatient admission significantly increased by 16% (CI = [0.11, 0.21], p < 0.00) for mobile crisis teams (MCTs) and significantly declined by 13% (CI = [-0.19, -0.07], p < 0.00) for BEST-designated emergency departments during the lockdown period compared to the prior year. CONCLUSIONS: The overall drop in PES utilization and the rise in inpatient admissions for MCT encounters suggests that during the early phases of the pandemic, patients delayed psychiatric care until they had a psychiatric crisis. Public health messaging about the lockdowns and absent equivalent messaging about the availability of telehealth services may have made patients more reluctant to seek psychiatric care.

Development of a Youth Civic Engagement Program: Process and Pilot Testing with a Youth-Partnered Research Team.

Although research suggests neighborhood-level factors influence youth well-being, few studies include youth when creating interventions to address these factors. We describe our three-step process of collaborating with youth in low-income communities to develop an intervention focused on civic engagement as a means to address neighborhood-level problems impacting their well-being. In the first step, we analyzed qualitative interviews from a project in which youth shared perceptions about their neighborhoods (e.g., interpersonal relations with neighbors and institutions). Three major themes were identified: pride in youth's communities, desire for change, and perceptions of power and responsibility. Based on these themes, we completed the second step: developing a civic engagement and leadership program, called LEAP, aimed at helping youth take an active role in addressing neighborhood problems. In the third step, we collaborated with youth who completed a pilot version of the civic program and provided feedback to finalize it for large-scale testing. While discussing our process, we highlight the importance of including youth voices when developing programs that affect them. Furthermore, we note the need for more research exploring whether civic engagement serves as a mechanism for encouraging youth involvement in addressing neighborhood-level health disparities and identifying potential psychological costs of such involvement.

Black clients in expansion states who used opioids were more likely to access medication for opioid use disorder after ACA implementation.

INTRODUCTION: Black people in the United States who use opioids receive less treatment and die from overdoses at higher rates than White people. Medication for opioid use disorder (MOUD) decreases overdose risk. Implementation of the Affordable Care Act (ACA) in the United States was associated with an increase in MOUD. To what extent racial disparity exists in MOUD following ACA implementation remains unclear. Using a national sample of people seeking treatment for opioids (clients), we compared changes in MOUD after the ACA to determine whether implementation was associated with increased MOUD for Black clients relative to White clients. METHODS: We identified 878,110 first episodes for clients with opioids as primary concern from SAMHDA's Treatment Episodes Dataset-Admissions (TEDS-A; 2007-2018). We performed descriptive and logistic regression analyses to estimate odds of MOUD for Black and White clients by Medicaid expansion status. We interacted ACA implementation with racial group and performed subpopulation analyses for Medicaid enrollees and criminal justice-referred clients. RESULTS: In expansion states post-ACA, MOUD increased from 33.6% to 51.3% for White clients and from 36.2% to 61.7% for Black clients. Pre-ACA, Black clients were less likely than White clients to use MOUD (adjusted odds ratio (aOR) = 0.88, 99th Confidence Interval (CI) = [0.85, 0.91]), and post-ACA, the change in odds of MOUD did not differ. Criminal justice-referred clients experienced less of a change in odds of MOUD among Black clients than among White clients (aOR = 0.74, CI = [0.62, 0.89]). Among Medicaid-insured clients, the change in odds of MOUD among Black clients was larger (aOR = 1.16, CI = [1.03, 1.30]). In the non-expansion states before 2014, Black clients were less likely to receive MOUD (aOR = 0.86, CI = [0.77, 0.95]) than White clients. After 2014, the change in odds of MOUD increased more for Black clients relative to White clients (aOR = 1.24, CI = [1.07, 1.44]). We did not find significant changes in MOUD for clients referred through the criminal justice system or with Medicaid. CONCLUSION: The ACA was associated with increased use of MOUD among Black clients and reduction in treatment disparity between Black and White clients. For criminal justice-referred Black clients, disparities in MOUD persist. Black clients with Medicaid in expansion states had the greatest reduction in disparities.

Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain.

OBJECTIVE: To determine whether the initial care provider for neck pain was associated with opioid use for individuals with neck pain. DESIGN: Retrospective cohort study. SETTING: Marketscan research databases. PARTICIPANTS: Patients (N=427,966) with new-onset neck pain from 2010-2014. MAIN OUTCOME MEASURES: Opioid use was defined using retail pharmacy fills. We performed logistic regression analysis to assess the association between initial provider and opioid use. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using bootstrapping logistic models. We performed propensity score matching as a robustness check on our findings. RESULTS: Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%-91% less likely to fill an opioid prescription in the first 30 days, and between 41%-87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47-3.69; P<.001). CONCLUSIONS: A patient's initial clinical contact for neck pain may be an important opportunity to influence subsequent opioid use. Understanding more about the roles that conservative therapists play in the treatment of neck pain may be key in unlocking new ways to lessen the burden of opioid use in the United States.

Implementing Social Determinants of Health Screening at Community Health Centers: Clinician and Staff Perspectives.

Purpose: Screening for social determinants of health (SDOH) during primary care office visits is recommended by pediatric and internal medicine professional guidelines. Less is known about how SDOH screening and service referral can be successfully integrated into clinical practice. Methods: Key informant interviews with 11 community health center (CHC) clinicians and staff members (medical assistants and case managers) were analyzed to identify themes related to integrating a SDOH screening and referral process (augmented WE CARE model) into their workflow. Results: CHC clinicians and staff believed the augmented WE CARE model benefited their patients and the CHC's mission. Most clinicians found the model was easy to implement. Some staff members had difficulty prioritizing the nonclinical intervention and were confused about their roles and the role of the patient navigator. The eligibility requirements and time needed to access local SDOH resources frustrated clinicians. Discussion: SDOH screening and referral care models can help support the mission of CHCs by identifying unmet material needs. However, CHCs have organizational and administrative challenges that successful interventions must address. CHCs need clinical champions for SDOH models because the screening and follow-up processes involve clinical staff. Additional support for SDOH models might include piloting the SDOH screening model workflow and formalizing the workflow before implementation, including the specific roles for clinicians, staff, and patient navigators.

Perceptions of employment-based discrimination among newly arrived foreign-educated nurses.

OBJECTIVE: To determine whether foreign-educated nurses (FENs) perceived they were treated equitably in the U.S. workplace during the last period of high international recruitment from 2003 to 2007. BACKGROUND: With experts predicting that isolated nursing shortages could return as soon as 2015, it is important to examine the lessons learned during the last period of high international recruitment in order to anticipate and address problems that may be endemic to such periods. In this baseline study, we asked FENs who were recruited to work in the United States between 2003 and 2007 about their hourly wages; clinical and cultural orientation to the United States; wages, benefits, and shift or unit assignments; and job satisfaction. METHODS: In 2008, we administered a survey to FENs who were issued VisaScreen certificates by the Commission on Graduates of Foreign Nursing Schools International between 2003 and 2007. We measured four outcomes of interest (hourly wages, job satisfaction, adequacy of orientation, and perceived discrimination) and conducted descriptive and regression analyses to determine if country of education and recruitment model were correlated with the outcomes. RESULTS: We found that 51% of respondents reported receiving insufficient orientation and 40% reported at least one discriminatory practice with regard to wages, benefits, or shift or unit assignments. FENs educated in low-income countries and those recruited by staffing agencies were significantly more likely than other FENs to report that they receive inequitable treatment compared with their U.S. counterparts. CONCLUSIONS: These findings raise both practical and ethical concerns that should interest those striving to create positive health care workplace environments and to ensure staff retention. Health care leaders should take steps to ensure that FENs are, and perceive that they are, treated equitably.

Overcoming barriers to a research-ready national commercial claims database.

OBJECTIVES: Billions of dollars have been spent on the goal of making healthcare data available to clinicians and researchers in the hopes of improving healthcare and lowering costs. However, the problems of data governance, distribution, and accessibility remain challenges for the healthcare system to overcome. STUDY DESIGN: In this study, we discuss some of the issues around holding, reporting, and distributing data, including the newest "big data" challenge: making the data accessible to researchers and policy makers. METHODS: This article presents a case study in "big healthcare data" involving the Health Care Cost Institute (HCCI). HCCI is a nonprofit, nonpartisan, independent research institute that serves as a voluntary repository of national commercial healthcare claims data. RESULTS: Governance of large healthcare databases is complicated by the data-holding model and further complicated by issues related to distribution to research teams. For multi-payer healthcare claims databases, the 2 most common models of data holding (mandatory and voluntary) have different data security requirements. Furthermore, data transport and accessibility may require technological investment. CONCLUSIONS: HCCI's efforts offer insights from which other data managers and healthcare leaders may benefit when contemplating a data collaborative.

Trends underlying employer-sponsored health insurance growth for Americans younger than age sixty-five.

Little is known about the trends in health care spending for the 156 million Americans who are younger than age sixty-five and enrolled in employer-sponsored health insurance. Using a new source of health insurance claims data, we estimated per capita spending, utilization, and prices for this population between 2007 and 2011. During this period per capita spending on employer-sponsored insurance grew at historically slow rates, but still faster than per capita national health expenditures. Total per capita spending for employer-sponsored insurance grew at an average annual rate of 4.9 percent, with prescription spending growing at 3.3 percent and medical spending growing at 5.3 percent. Out-of-pocket medical spending increased at an average annual rate of 8.0 percent, whereas out-of-pocket prescription drug spending growth was flat. Growth in the use of medical services and prescription drugs slowed. Medical price growth accelerated, and prescription price growth decelerated. As a result, changes in utilization contributed less than changes in price did to overall spending growth for those with employer-sponsored insurance.

Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care.

This study tests whether changes in licensed nurse staffing led to changes in patient safety, using the natural experiment of 2004 California implementation of minimum staffing ratios. We calculated counts of six patient safety outcomes from California Patient Discharge Data from 2000 through 2006, using the Agency for Healthcare Research and Quality Patient Safety Indicators (PSI) software. For patients experiencing nonmortality-related PSIs, we measured mean lengths of stay. We estimated difference-in-difference equations of changes in PSIs using Poisson models and calculated the marginal impact of nurse staffing on outcomes from fixed-effect Poisson regressions. Licensed nurse staffing increased in the postregulation period, except for hospitals in the highest quartile of preregulation staffing. Growth in registered nurse staffing was associated with improvement for only one PSI and reduced length of stay for one PSI. Higher registered nurse staffing per patient day had a limited impact on adverse events in California hospitals.

Healthcare employers' policies on nurse education.

The 2010 recommendation that the proportion of registered nurses with BSN (bachelor of science in nursing) degrees in the nursing workforce should increase from the current 40% to 80% by the year 2020 has shifted the focus on nurses educational progression from state legislatures-where changes in entry-level requirements were debated for decades-to the executive suites of large healthcare providers. The recommendation, contained in the report titled The Future of Nursing: Leading Change, Advancing Health, by the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, suggests that human resources policies for nurses have the potential to double the rates of college degree completions (IOM, 2010). We surveyed 447 nurse executives in hospitals, nurse-led clinics, and home and hospice companies to explore the current practices of healthcare employers with regard to this recommendation. Almost 80% of respondents reported that their institution either preferred or required newly hired nurses to have a bachelor's degree, and 94% of the facilities offered some level of tuition reimbursement. Only 25%, however, required their nurses to earn a BSN or offered salary differentials on the basis of educational attainment (9%). We conclude that if employers are serious about wanting a more highly educated nurse workforce, they need to adopt requirements for degree completion and wage differentials in the coming years. The likelihood that such policies will be widely adopted, however, is dramatically affected by the dynamics of nursing supply and demand.

Hospital RN job satisfaction and nurse unions.

The objective of the study was to examine whether unionization is associated with job satisfaction among RNs in the United States using nationally representative surveys of RNs. Factors that predict job satisfaction for RNs in healthcare continue to be of great concern to nurse administrators and managers because job satisfaction remains an important aspect of nurse retention. In addition, the notion of having unions for RNs has also gained prominence on the national stage. The relationship between RN job satisfaction and having an RN union has rarely been studied, but in 2 studies, a paradox was found; hospitals with RN unions had higher job dissatisfaction but greater retention. This study will test the relationship between having an RN union and job satisfaction with data that are both more recent and nationally representative. We analyze the public-use data from the 2004 and 2008 National Sample Surveys of Registered Nurses. In both 2004 and 2008, union representation was negatively associated with job satisfaction, although this relationship was not statistically significant in 2008. Some nurse administrators and executives would not be surprised by this finding. However, although union nurses may express more dissatisfaction, they may also be more vocal and less fearful about voicing concerns. If managers can harness this ability of the nurses to be articulate and outspoken, working with unions and union nurses can be productive and satisfying.