Human Services and Behavioral Health Integration: A Model for Whole-Person Medicaid Managed Care.

A comprehensive, whole-person approach to individuals' health care can be achieved by aligning, integrating, and coordinating health services with other human services. HealthChoices, Pennsylvania's managed Medicaid program, delegates responsibility for Medicaid-funded behavioral health service management to individual counties or multicounty collaboratives. County administrators' programmatic and fiscal oversight of Medicaid-funded services allows them to create synergies between behavioral health and other human service delivery systems and to set priorities on the basis of local needs. This model supports access to community-based care, integration of general medical and behavioral health services, and programs that address social determinants of health.

Care Management Intervention to Address Determinants of Health for Individuals With Multiple Behavioral Health Readmission.

PURPOSE OF STUDY: To examine the effectiveness of a care management intervention to decrease readmissions and to better understand clinical and social determinants associated with readmission. PRIMARY PRACTICE SETTING: Inpatient mental health (MH) and substance use disorder (SUD) facilities, nonhospital SUD withdrawal management and rehabilitation facilities. METHODOLOGY AND SAMPLE: The authors identified 3,950 Medicaid-enrolled individuals who received the intervention from licensed clinical staff of a behavioral health managed care organization; 2,182 individuals were eligible but did not receive the intervention, for treatment as usual (TAU). We used logistic regression to examine factors associated with readmission. Determinants of readmission were summarized through descriptive tests. RESULTS: The intervention was associated with lower readmissions to SUD facilities compared with TAU (6.0% vs. 8.6%, p = .0002) and better follow-up to aftercare. Controlling for clinical differences between groups, regression results found increased odds of readmission for male gender (odds ratio [OR]: 1.33; 95% confidence interval [CI]: 1.16-1.52, p < .0001) and dual MH and SUD diagnoses (OR: 1.52; CI: 1.29-1.79, p < .0001). Prior inpatient and case management services were also associated with increased odds for readmission. In the regression model, the intervention was not associated with decreased odds for readmission. Individuals with readmission (n = 796) were more likely to report being prescribed psychotropic medication and having housing difficulties and less likely to report having a recovery plan than those without readmission. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Characteristics of Medicaid populations with hospitalization may contribute to readmission, which may be mitigated through care management intervention.

Association of Counseling and Psychotherapy on Retention in Medication for Addiction Treatment Within a Large Medicaid Population.

OBJECTIVES: Buprenorphine/naloxone is an effective medication for the treatment of opioid use disorder. Unlike methadone, which can only be dispensed in federally waived clinics and which must be combined with specific psychosocial treatment, buprenorphine can be dispensed by individual prescribers who have completed an 8-hour training program, with no requirement that patients receive concomitant psychotherapy. The objective of this study is to quantify the association of counseling and psychotherapy on retention in treatment. We also examine the effect of buprenorphine dosage on retention. METHODS: We examined a cohort of 4987 members of a not-for-profit managed care organization serving Medicaid members in 41 counties in Pennsylvania. This cohort was selected from all members who had a full year without any medication for opioid use disorder followed by initiation of treatment with buprenorphine/naloxone in 2016 to 2017 and who remained Medicaid eligible for at least 80% of the following 2 years. Outcomes were estimated using inverse probability weighted propensity scores. RESULTS: The addition of counseling and psychotherapy within the first 8 weeks of treatment was associated with greater total retention in treatment and there was a dose-response relationship. A 16 mg/d or greater dose of buprenorphine was also associated with greater retention. CONCLUSIONS: These results provide support for an integrated approach to treating people with an opioid use disorder, through a combination of buprenorphine pharmacotherapy and targeted counseling and psychotherapy within the first 2 months of treatment.

Increased likelihood of psychiatric readmission with Medicaid expansion vs legacy coverage.

OBJECTIVES: To compare patterns of psychiatric hospitalization and readmission within 30 days for Medicaid expansion (expansion) vs previously insured (legacy) samples. STUDY DESIGN: Retrospective analysis using Medicaid behavioral health service claims. METHODS: We identified 24,044 individuals with hospitalizations in calendar years 2017 and 2018 within the network of a behavioral health managed care organization in Pennsylvania. Logistic regression was used to examine factors associated with readmission. RESULTS: Individuals covered under expansion (n = 7747) vs legacy (n = 16,297) were older and more likely to be male and European American, with higher rates of cooccurring mental health (MH) and substance use disorder (SUD) diagnoses, as well as lower rates of MH and SUD services in the 30 days prior and any prior MH hospitalization. A higher proportion of individuals with expansion vs legacy status were readmitted (11.3% vs 9.0%; P < .0001). Controlling for factors associated with readmission, regression showed an increased likelihood of readmission for expansion vs legacy status (adjusted odds ratio [AOR], 1.23; 95% CI, 1.12-1.35; P < .0001). Increased risk for readmission was also found across populations for male patients (AOR, 1.12; 95% CI, 1.02-1.22; P = .0124), those with prior MH hospitalizations (AOR, 1.65; 95% CI, 1.51-1.81; P < .0001) or other behavioral health services (AOR, 1.14; 95% CI, 1.03-1.26; P = .0142), those with longer hospitalization episodes (AOR, 1.01; 95% CI, 1.00-1.01; P < .0001), and those with cooccurring SUD (AOR, 1.58; 95% CI, 1.44-1.74; P < .0001). CONCLUSIONS: Individuals with coverage through Medicaid expansion compared with legacy coverage have an increased risk of psychiatric readmission and may warrant targeted interventions that also address service utilization and cooccurring SUD.

Payer-Provider Partnership to Identify Successful Retention Strategies for the Behavioral Health Workforce.

BACKGROUND: High staff turnover rates are a burden for behavioral health providers because they may negatively impact staff morale, quality of care, and clinical outcomes as well as increase costs. The Staff Assessment and Retention (STAR) Project is a partnership between a behavioral health managed care organization and community-based providers designed to: 1) share information on research-based approaches, 2) identify strategies that providers find successful yet feasible, and 3) develop a learning community around research-based, community-informed strategies to increase staff retention. METHODS: Participants from 87 community-based behavioral health providers completed a survey about successful strategies and barriers to staff retention, current retention and turnover rates, and ratings of commonly used strategies supported by research. Results were shared and discussed across the partnership through a learning community including a webinar co-facilitated by two participating providers. RESULTS: Successfully demonstrated but less utilized strategies included use of exit and stay interviews, training in best practices, availability of electronic records and other technology, and flexible work schedules. Providers reported the type of employment offered (full or part time, benefits, competitive wage; reported in 17% of responses), ability to offer trainings and staff development (13%) and using staff feedback (10%) were most important to retention. CONCLUSIONS: The partnership demonstrated that providers desire a vehicle for sharing ideas and problem-solving issues related to the behavioral health workforce. The endorsement by several community-based providers of lower-utilized strategies known to improve retention would not be realized across the community without the collaboration of the payer-provider partnership.

Appropriate Use of Drug Testing in Clinical Addiction Medicine.

: Biological drug testing is a tool that provides information about an individual's recent substance use. Like any tool, its value depends on using it correctly; that is, on selecting the right test for the right person at the right time. This document is intended to clarify appropriate clinical use of drug testing in addiction medicine and aid providers in their decisions about drug testing for the identification, diagnosis, treatment, and recovery of patients with, or at risk for, addiction. The RAND Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Method (RAM) process for combining scientific evidence with the collective judgment of experts was used to identify appropriate clinical practices and highlight areas where research is needed. Although consensus panels and expert groups have offered guidance on the use of drug testing for patients with addiction, very few addressed considerations for patients across settings and in different levels of care. This document will focus primarily on patients in addiction treatment and recovery, where drug testing is used to assess patients for a substance use disorder, monitor the effectiveness of a treatment plan, and support recovery. Inasmuch as the scope includes the recognition of addiction, which often occurs in general healthcare settings, selected special populations at risk for addiction visiting these settings are briefly included.

Are general and strategic measures of organizational context and leadership associated with knowledge and attitudes toward evidence-based practices in public behavioral health settings? A cross-sectional observational study.

BACKGROUND: Examining the role of modifiable barriers and facilitators is a necessary step toward developing effective implementation strategies. This study examines whether both general (organizational culture, organizational climate, and transformational leadership) and strategic (implementation climate and implementation leadership) organizational-level factors predict therapist-level determinants of implementation (knowledge of and attitudes toward evidence-based practices). METHODS: Within the context of a system-wide effort to increase the use of evidence-based practices (EBPs) and recovery-oriented care, we conducted an observational, cross-sectional study of 19 child-serving agencies in the City of Philadelphia, including 23 sites, 130 therapists, 36 supervisors, and 22 executive administrators. Organizational variables included characteristics such as EBP initiative participation, program size, and proportion of independent contractor therapists; general factors such as organizational culture and climate (Organizational Social Context Measurement System) and transformational leadership (Multifactor Leadership Questionnaire); and strategic factors such as implementation climate (Implementation Climate Scale) and implementation leadership (Implementation Leadership Scale). Therapist-level variables included demographics, attitudes toward EBPs (Evidence-Based Practice Attitudes Scale), and knowledge of EBPs (Knowledge of Evidence-Based Services Questionnaire). We used linear mixed-effects regression models to estimate the associations between the predictor (organizational characteristics, general and strategic factors) and dependent (knowledge of and attitudes toward EBPs) variables. RESULTS: Several variables were associated with therapists' knowledge of EBPs. Clinicians in organizations with more proficient cultures or higher levels of transformational leadership (idealized influence) had greater knowledge of EBPs; conversely, clinicians in organizations with more resistant cultures, more functional organizational climates, and implementation climates characterized by higher levels of financial reward for EBPs had less knowledge of EBPs. A number of organizational factors were associated with the therapists' attitudes toward EBPs. For example, more engaged organizational cultures, implementation climates characterized by higher levels of educational support, and more proactive implementation leadership were all associated with more positive attitudes toward EBPs. CONCLUSIONS: This study provides evidence for the importance of both general and strategic organizational determinants as predictors of knowledge of and attitudes toward EBPs. The findings highlight the need for longitudinal and mixed-methods studies that examine the influence of organizational factors on implementation.

Composite Diffuse Large B-cell and Mantle Cell Lymphoma: A Case Report.

Composite lymphoma is an extremely rare clinical entity and is characterized by the presence of two different subtypes of lymphoma in the same lymph node. We report a case of composite lymphoma in a 57-year-old male presenting with leg and groin pain. The right inguinal lymph node biopsy showed large and small cells. Immunohistochemistry was consistent with large cells staining for diffuse large B-cell lymphoma (DLBCL) and small cells positive for mantle cell lymphoma (MCL). Polymerase chain reaction (PCR) analysis of immunoglobulin heavy (IGH) chain and immunoglobulin kappa (IGK) light chain gene rearrangements confirmed that the two were clonally unrelated neoplasms. There are only two reported cases of composite lymphoma with this combination in the published English literature. We report the third such case and discuss the pathology, diagnostic challenges and management of composite lymphoma.

Synchronizing Watches: The Challenge of Aligning Implementation Science and Public Systems.

This special issue of Administration and Policy in Mental Health explores the complexities of the outer system context in implementation science research. In this commentary, we highlight areas of asynchrony between implementation science research and policy realities of public systems. Timing is a critical factor for many aspects of system-level implementation including when and how evidence-based practice initiatives are launched, short and inconsistent timeframes for funding and support, need for early indicators of success and demonstrating return on investment. Greater consideration for the timing that drives change in public systems will strengthen efforts to implement and sustain EBPs in community settings.

Systemic Mastocytosis with Smoldering Multiple Myeloma: Report of a Case.

Systemic mastocytosis (SM) is a disease characterized by a clonal infiltration of mast cells affecting various tissues of the body. It is grouped into six different subtypes according to the World Health Organization classification. It is called indolent systemic mastocytosis (ISM) when there is no evidence of end organ dysfunction, while the presence of end organ dysfunction defines aggressive systemic mastocytosis (ASM). When SM coexists with a clonal hematological disorder, it is classified as systemic mastocytosis with associated clonal hematological nonmast cell lineage disease (SM-AHNMD). Over 80% of SM-AHNMD cases involve disorders of the myeloid cell lines. To our knowledge, there are only 8 reported cases to date of SM associated with a plasma cell disorder. We report a patient with ISM who was found to have concomitant smoldering multiple myeloma. His disease later progressed to ASM. We discuss this rare association between SM and a plasma cell disorder, and potential common pathophysiologic mechanisms linking the two disorders will be reviewed. We also discuss prognostic factors in SM as well as the management options considered during the evolution of the patient's disease.

Applying the Policy Ecology Framework to Philadelphia's Behavioral Health Transformation Efforts.

Raghavan et al. (Implement Sci 3(26):1-9, 2008) proposed that effective implementation of evidence-based practices requires implementation strategies deployed at multiple levels of the "policy ecology," including the organizational, regulatory or purchaser agency, political, and social levels. However, much of implementation research and practice targets providers without accounting for contextual factors that may influence provider behavior. This paper examines Philadelphia's efforts to work toward an evidence-based and recovery-oriented behavioral health system, and uses the policy ecology framework to illustrate how multifaceted, multilevel implementation strategies can facilitate the widespread implementation of evidence-based practices. Ongoing challenges and implications for research and practice are discussed.

Quality of Diabetes Care Among Adult Medicaid Enrollees With Mental Disorders.

OBJECTIVE: In light of the national trend toward integrating mental and general medical care, this study examined disparities in diabetes treatment among Medicaid recipients in a nonintegrated, managed care behavioral health carve-out system. METHODS: A retrospective study of Medicaid claims (July 2009-June 2010) compared quality of diabetes treatment among 21,015 patients with and without mental disorders. RESULTS: Presence of a mental disorder was associated with higher use of outpatient and primary care services for diabetes, lower rates of hospitalizations for diabetes, and higher odds of receiving three or more quality measures for diabetes care. Patients with serious mental illness had better diabetes care compared with patients with other mental disorders and patients with no mental disorders. CONCLUSIONS: Findings suggest that managed care behavioral health carve-out systems should be considered among the range of approaches for improving treatment for diabetes among persons with comorbid mental disorders, particularly serious mental disorders.

Independent Contractors in Public Mental Health Clinics: Implications for Use of Evidence-Based Practices.

OBJECTIVES: Community mental health clinics are increasingly utilizing independent contractors to provide clinical services. At the same time, many organizations are participating in initiatives intended to increase implementation of evidence-based practices (EBPs). The primary aim of this study was to understand the associations of utilizing independent contractors with clinician knowledge and attitudes toward EBPs and organizational culture and climate. The study also sought to understand the potential impact of using independent contractors on mental health services delivery from the perspective of organizational leadership. METHODS: Quantitative data were collected from 130 therapists in 23 organizations; qualitative data were collected from executive administrators in nine of the 16 organizations participating in EBP initiatives sponsored by the City of Philadelphia. Regression with random effects was used to estimate the associations between worker status (contractor or employee) and clinician attitudes toward EBPs, knowledge of EBPs, and organizational culture and climate. Qualitative inquiry was used to understand the impact of reliance on independent contractors on organizational participation in EBP initiatives. RESULTS: Independent contractors endorsed less positive attitudes toward EBPs and scored lower on knowledge of EBPs. Interviews revealed four main themes: reasons for using independent contractors, general consequences of using independent contractors, specific impact of independent contractors on participation in EBP initiatives, and suggestions for alternatives. CONCLUSIONS: A growing number of community mental health clinics rely on independent contractors. There may be consequences of this shift that deserve exploration.

Therapist- and Client-Level Predictors of Use of Therapy Techniques During Implementation in a Large Public Mental Health System.

OBJECTIVE: Many youths receiving community mental health treatment do not receive evidence-based interventions. Research suggests that community mental health therapists use a broad range of therapeutic techniques at low intensities. This study examined the relationship between therapist- and client-level predictors of community-based therapists' report of cognitive, behavioral, psychodynamic, and family techniques within the context of implementation efforts. METHODS: A total of 130 therapists participated from 23 organizations in an urban, publicly funded behavioral health system implementing evidence-based practices. Therapist-level predictors included age, gender, clinical experience, licensure status, and participation in evidence-based practice initiatives. Child-level predictors included therapist-reported child primary disorder (externalizing, internalizing, or other) and child age. Therapists completed the Therapist Procedures Checklist-Family Revised, a self-report measure of therapeutic techniques used. RESULTS: Unlicensed therapists were more likely than licensed therapists to report using psychodynamic and behavioral techniques. Therapists who did not participate in an evidence-based practice initiative were less likely to report use of cognitive techniques. Those with clients with externalizing disorders were more likely to report use of behavioral and family techniques. Therapists with the youngest clients (ages three to seven years) were most likely to report use of behavioral techniques and less likely to report use of cognitive and psychodynamic techniques. CONCLUSIONS: Results suggest that both therapist and client factors predict self-reported use of therapy techniques. Participating in an evidence-based practice initiative was associated with increased reports of using cognitive techniques. Therapists reported using behavioral and family techniques more than other techniques when working with youths with externalizing disorders and using fewer cognitive and psychodynamic techniques with young clients.

A Multi-Level Examination of Stakeholder Perspectives of Implementation of Evidence-Based Practices in a Large Urban Publicly-Funded Mental Health System.

Our goal was to identify barriers and facilitators to the implementation of evidence-based practices from the perspectives of multiple stakeholders in a large publicly funded mental health system. We completed 56 interviews with three stakeholder groups: treatment developers (n = 7), agency administrators (n = 33), and system leadership (n = 16). The three stakeholder groups converged on the importance of inner (e.g., agency competing resources and demands, therapist educational background) and outer context (e.g., funding) factors as barriers to implementation. Potential threats to implementation and sustainability included the fiscal landscape of community mental health clinics and an evolving workforce. Intervention characteristics were rarely endorsed as barriers. Inner context, outer context, and intervention characteristics were all seen as important facilitators. All stakeholders endorsed the importance of coordinated collaboration across stakeholder groups within the system to successfully implement evidence-based practices.

The Perfect Storm: Collision of the Business of Mental Health and the Implementation of Evidence-Based Practices.

Financing has been hypothesized to be an important driver of the implementation of evidence-based practices (EBPs), yet there has been little systematic investigation of financing as a factor in EBP implementation. This column presents findings from a qualitative study of the effects of financial factors on the implementation of EBPs in a large urban publicly funded mental health system. Interviews with 33 agency leaders and 16 policy makers identified financial distress in community mental health agencies, leading to concerns about complex and expensive implementation of EBPs. Stakeholders agreed that the cost of EBP implementation should be shared between the agencies and the system; however, the stakeholders did not agree on how EBPs should be financed.

A Prospective Examination of Clinician and Supervisor Turnover Within the Context of Implementation of Evidence-Based Practices in a Publicly-Funded Mental Health System.

Staff turnover rates in publicly-funded mental health settings are high. We investigated staff and organizational predictors of turnover in a sample of individuals working in an urban public mental health system that has engaged in a system-level effort to implement evidence-based practices. Additionally, we interviewed staff to understand reasons for turnover. Greater staff burnout predicted increased turnover, more openness toward new practices predicted retention, and more professional recognition predicted increased turnover. Staff reported leaving their organizations because of personal, organizational, and financial reasons; just over half of staff that left their organization stayed in the public mental health sector. Implications include an imperative to focus on turnover, with a particular emphasis on ameliorating staff burnout.

Babesia in a Nonsplenectomized Patient Requiring Exchange Transfusion.

Babesiosis is a tick born zoonosis caused by red blood cell parasites of the genus Babesia. It is caused predominantly by B. microti and B. divergens, microti being more common in the US. The parasites are transmitted by Ixodes tick to their host but infection can also spread by blood transfusion and perinatally. Clinical manifestations vary from subclinical infection to fulminating disease depending upon the immune status of the patient. About half of patients, hospitalized with babesiosis, develop complication with fatality rates of 6 to 9% which increase up to 21% among those with immunosuppression. A case of 58-year-old previously healthy man, infected by B. microti, was reported on 2000 who presented with severe disease characterized by severe anemia, DIC, and renal and respiratory failure. First case of overwhelming septic shock without respiratory involvement due to babesiosis in a healthy patient with an intact spleen was published in a case report on 2011. Since our patient here is an immunocompetent healthy male with intact spleen presenting with severe babesiosis requiring exchange transfusion, this presentation of Babesia is rare and warrants further study.