Assessing the social determinants of health care costs for Medicaid-enrolled adolescents in Washington State using administrative data.

OBJECTIVE: The study used administrative data to identify the social determinants that have the greatest impact on Medicaid expenditures in adolescence. DATA SOURCES: Data were compiled using the Washington State Department of Social and Health Services Integrated Client Databases, which link data from state systems including Medicaid claims and social services receipt. STUDY DESIGN: Medical system and behavioral health service costs of over 180 000 Medicaid-enrolled adolescents aged 12-17 were measured using integrated administrative data from Washington State. Social determinants of health, including child maltreatment and parent risk factors, were also measured. Two-stage regression models were used to identify factors associated with increased health care utilization and costs. PRINCIPAL FINDINGS: Regression models revealed that the factors most predictive of higher health care costs were child abuse, child neglect, and instability in out-of-home placements related to foster care. Other social determinants of health, such as parent risk factors, were not associated with health care costs. Child maltreatment and placement instability impacted health care costs primarily through large increases in behavioral health utilization and costs. CONCLUSIONS: Prevention and early interventions for children and families to decrease child maltreatment and increase foster care placement stability could reduce overall health care costs.

Using State Administrative Data to Identify Social Complexity Risk Factors for Children.

PURPOSE: Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use. METHODS: We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use. RESULTS: Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14). CONCLUSIONS: State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.

Childhood adversity and behavioral health outcomes for youth: An investigation using state administrative data.

This study aimed to measure the relative contribution of adverse experiences to adolescent behavioral health problems using administrative data. Specifically, we sought to understand the predictive value of adverse experiences on the presence of mental health and substance abuse problems for youth receiving publicly funded social and health services. Medicaid claims and other service records were analyzed for 125,123 youth age 12-17 and their biological parents. Measures from administrative records reflected presence of parental domestic violence, mental illness, substance abuse, criminal justice involvement, child abuse and/or neglect, homelessness, and death of a biological parent. Mental health and substance abuse status of adolescents were analyzed as functions of adverse experiences and other youth characteristics using logistic regression. In multivariate analyses, all predictors except parental domestic violence were statistically significant for substance abuse; parental death, parental mental illness, child abuse or neglect and homelessness were statistically significant for mental illness. Odds ratios for child abuse/neglect were particularly high in both models. The ability to identify risks during childhood using administrative data suggests the potential to target prevention and early intervention efforts for children with specific family risk factors who are at increased risk for developing behavioral health problems during adolescence. This study illustrates the utility of administrative data in understanding adverse experiences on children and the advantages and disadvantages of this approach.

Impact of sexual orientation and co-occurring disorders on chemical dependency treatment outcomes.

OBJECTIVE: The aims of this study were to compare client characteristics at admission to chemical dependency (CD) treatment by sexual orientation, examine sexual orientation as a predictor of co-occurring CD and mental health problems (hereafter referred to as co-occurring disorders [COD]), and to examine the effect of sexual orientation and COD on 1-year CD treatment outcomes (treatment completion, treatment reentry, and arrest) among men and women. METHOD: This retrospective cohort study used 2004-2008 data from publicly funded CD treatment programs in Washington State (n = 69,525 clients). Bivariate comparisons were made using chi-square tests; logistic and Cox regressions were to estimate risk in multivariate analyses. RESULTS: Risk factors associated with sexual minority status (lesbian/gay/bisexual) included COD, primary drug (vs. alcohol) use, and greater substance use. In multivariate analyses, sexual minority clients were more than twice as likely as their heterosexual counterparts to have COD. COD, but not sexual orientation, negatively predicted treatment completion and arrest overall in the year following treatment among male and female clients and positively predicted treatment reentry and intimate partner violence-related arrest among women. COD moderated the effect of sexual orientation on arrest; gay men with COD were less likely to be arrested, particularly for substance use and other violence-related crimes. CONCLUSIONS: These findings highlight the importance of assessing mental health among sexual minority clients in treatment settings and addressing issues specific to both female and male sexual minorities.

The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans.

This study examined the mental health impact of reported direct and indirect killing among 2,797 U.S. soldiers returning from Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 40% of soldiers reported killing or being responsible for killing during their deployment. Even after controlling for combat exposure, killing was a significant predictor of posttraumatic disorder (PTSD) symptoms, alcohol abuse, anger, and relationship problems. Military personnel returning from modern deployments are at risk of adverse mental health conditions and related psychosocial functioning related to killing in war. Mental health assessment and treatment should address reactions to killing to optimize readjustment following deployment.

History and implementation of the Fort Lewis Soldier Wellness Assessment Program (SWAP).

The Department of Defense mandates a health reassessment at 90 to 180 days following return from deployment. Essential components include a review of mental and physical health symptoms and follow-up referral. Fort Lewis developed a program that exceeds these basic requirements to provide additional screening and on-site services, including face-to-face visits with a credentialed mental health provider for all soldiers. This program, the Soldier Wellness Assessment Program (SWAP), also extends these services to the predeployment window (120 to 45 days) to identify problems before deployment early enough to treat them. Data from the anonymous SWAP Quality Improvement Questionnaire (N=7880) suggested that the majority of service members felt their experience at the SWAP increased their willingness to seek out behavioral health (BH) services in the future, if needed. SWAP provides a model for a deployment-related individual mental health visit for all soldiers, customized for their specific health concerns.

Impact of Access to Recovery services on alcohol/drug treatment outcomes.

The purpose of this study was to assess the impact of providing recovery support services to clients receiving publicly funded chemical dependency (CD) treatment through the Access to Recovery (ATR) Program in Washington State. Services included case management, transportation, housing, and medical. A comparison group composed of clients who received CD treatment only was constructed using a multistep procedure based on propensity scores and exact matching on specific variables. Outcomes were obtained from administrative data sources. Results indicated that ATR services were associated with a number of positive outcomes including increased length of stay in treatment, increased likelihood of completing treatment, and increased likelihood of becoming employed. The beneficial effects of ATR services on treatment retention were most pronounced when they were provided between 31 and 180 days after treatment began. The results reported here offer evidence for the value of ATR services.

Screening soldiers in outpatient care for mental health concerns.

Significant recent effort has been directed toward screening and describing military populations in relation to deployment. Missing from these recent efforts is information describing screened mental health symptoms for the population of active duty military that are seen for mental health services. This article presents mental health screening data for 2,882 soldiers seeking services at a military facility outpatient behavioral health clinic. Screening positive for multiple symptom domains was common, with >60% of the sample screening positive for more than one clinical symptom domain. Post-traumatic stress disorder and depression were among the most commonly identified disorders, followed by alcohol abuse. This screening data, gathered using measures similar to those used in published deployment-related screening efforts, suggest differences that exist between the clinical population and the overall military population, providing some insights into the rates of clinical symptomatology within the military health system and providing a point of comparison for population- screening efforts. Clinical implications include the importance of provider awareness to the high rates of comorbidity across symptom domains.

Relative impact of adverse events and screened symptoms of posttraumatic stress disorder and depression among active duty soldiers seeking mental health care.

Symptoms of depression and posttraumatic stress are among the most studied psychological difficulties among soldiers. Such symptoms have been linked to a history of adverse events among both civilians and combat veterans. There is a paucity of research on this topic that can be applied to an active duty clinical population. Intake screening data were reviewed for 1,626 soldiers presenting to an outpatient mental health clinic to identify variables, including history of potentially traumatic experiences, associated with screened symptoms of posttraumatic stress disorder (PTSD) and depression. Demographics such as age, gender, and military rank, as well as number of adverse childhood experiences were significant predictors of screened PTSD and depression. A history of deployment to a combat zone predicted screened PTSD, but not depression. The role of childhood abuse as a risk factor is discussed and highlighted in the etiology of symptoms for soldiers seeking mental health care.

Negative Affect and HIV Risk in Alcohol and Other Drug (AOD) Abusing Adolescent Offenders.

Various depressive symptoms have been linked to elevated levels of HIV risk across diverse adult populations in multiple studies. However, this link has been examined in a much more limited manner among adolescents, despite an exceedingly heightened risk of both HIV and negative affect in this age group. To address the current lack of clinically pertinent knowledge in this area, we analyzed baseline data from 256 male and 107 female inner city, culturally diverse adolescent offenders. Relatively "high" and "low" negative affect subgroups were formed by conducting a median split on scores from the well-validated depressive affect scale of the Millon Adolescent Clinical Inventory (MACI). Compared to the low negative affect subgroup, the high negative affect participants reported significantly more sexual partners, unprotected sex, and increased susceptibility to HIV, as well as more marijuana, cocaine, and alcohol use (all p's < .05). Although demonstrating better condom skills, negative affect participants reported less favorable attitudes towards using condoms, less knowledge about HIV transmission, and lower sexual self-efficacy than non-depressive participants. Symptoms of negative affect are therefore of particular concern for adolescents, who are at risk not only for generally acknowledged difficulties such as suicide, but also for multiple HIV risk factors. The theoretical and applied implications of these findings will be discussed.

Audio-CASI vs interview method of administration of an HIV/STD risk of exposure screening instrument for teenagers.

Previous research conducted to examine the implications of using audio-computerized (A-CASI) procedures to gather sensitive sexual behaviour data has provided mixed results. The purpose of this study was to assess differences in the disclosure of HIV risk behaviours between subjects interviewed face to face and subjects interviewed using A-CASI procedures. An HIV/STD risk of exposure screening instrument was administered to 265 male and female adolescents in the juvenile justice system. T-test analyses revealed that adolescents assessed using A-CASI procedures endorsed fewer items on the HIV/STD screen than those interviewed by an assessor. In addition, those in the A-CASI group endorsed fewer items with explicit sexual or drug content and fewer subtle items. Results of this study suggest that A-CASI may not be suitable for use among adolescents in the juvenile justice system when assessing undesirable and/or illegal behaviours.

Impulsivity and HIV risk among adjudicated alcohol- and other drug-abusing adolescent offenders.

Although impulsivity is likely to be related to HIV risk--particularly in incarcerated substance-abusing youth--this area of research has been understudied. To investigate the relationship between impulsivity and various HIV/AIDS risk behaviors and attitudes, a sample of court-referred and incarcerated culturally diverse inner-city adolescents (males: N = 266; females: N = 111) were divided into high and low impulsive groups based on the Millon Adolescent Clinical Inventory Impulsivity Scale. Findings showed that compared to the less impulsive group, the highly impulsive adolescents reported more frequent marijuana and alcohol use in the last 3 months as well as a significantly higher proportion of unprotected sex when high on alcohol and marijuana, higher perceived susceptibility to HIV, more AIDS-related anxiety, greater HIV knowledge, less sexual self-efficacy, and less favorable sexual attitudes. Implications for interventions among incarcerated youth are discussed.