Behavioral health indicators and time-to-rearrest in an adult pre-arrest diversion program.

Several states have recently adopted legislation in support of pre-arrest diversion programs that give police the authority to refer adults with behavioral health needs to treatment providers instead of placing them under arrest and booking them into local jails. The Adult Civil Citation program has been operating since 2013 to divert adults accused for the first time of a misdemeanor offense to a community behavioral health provider with the primary goal of addressing underlying needs that are likely to be associated with future criminal justice contact. The current study analyzed data from a sample of 1,071 adults who participated in the program to assess the impact of behavioral health indicators on time-to-rearrest. Adults who presented greater behavioral health needs were more likely to come into subsequent contact with police, but these indications did not influence the amount of time that lapsed between program participation and rearrest events.

A Positive Behavioral Approach for Aggression in Forensic Psychiatric Settings.

Aggression toward self and others by complex patients admitted to forensic psychiatric settings is a relatively common yet extremely difficult behavior to treat. Traditional interventions in forensic inpatient settings have historically emphasized control and management over treatment. Research over the past several years has demonstrated the value of behavioral and psychosocial treatment interventions to reduce aggression and to increase prosocial skill development in inpatient forensic population. Positive behavioral support (PBS) offers a comprehensive approach that incorporates the science of applied behavioral analysis (ABA) in support of patients with challenging behaviors, including aggression and violence. In this article, we describe a PBS model to treat aggression in forensic settings. PBS includes a comprehensive functional assessment, along with four basic elements: ecological strategies, positive programming, focused support strategies, and reactive strategies. Other key components are described, including data collection, staff training, fidelity checks to ensure correct implementation of the plan, and ongoing monitoring and revision of PBS strategies, according to treatment outcomes. Finally, a behavioral consultation team approach within the inpatient forensic setting is recommended, led by an assigned doctoral-level psychologist with specialized knowledge and training in behavioral methods. The behavioral consultation team works directly with the unit treatment team and the identified patient to develop, implement, and track a plan that may extend over several weeks to several months including transition into the community. PBS can offer a positive systemic impact in forensic inpatient settings, such as providing a nonpharmacologic means to address aggression, reducing the incidences of restraint and seclusion, enhancing staff proficiency in managing challenging patient presentations, and reducing recidivism when used as part of the bridge to community re-entry.

Integrating Behavioral Health in Primary Care Using Lean Workflow Analysis: A Case Study.

BACKGROUND: Primary care offices are integrating behavioral health (BH) clinicians into their practices. Implementing such a change is complex, difficult, and time consuming. Lean workflow analysis may be an efficient, effective, and acceptable method for use during integration. The objectives of this study were to observe BH integration into primary care and to measure its impact. METHODS: This was a prospective, mixed-methods case study in a primary care practice that served 8,426 patients over a 17-month period, with 652 patients referred to BH services. Secondary measures included primary care visits resulting in BH referrals, referrals resulting in scheduled appointments, time from referral to the scheduled appointment, and time from the referral to the first visit. Providers and staff were surveyed on the Lean method. RESULTS: Referrals increased from 23 to 37 per 1000 visits (P < .001). Referrals resulted in more scheduled (60% to 74%; P < .001) and arrived visits (44% to 53%; P = .025). Time from referral to the first scheduled visit decreased (hazard ratio, 1.60; 95% confidence interval, 1.37-1.88) as did time to first arrived visit (hazard ratio, 1.36; 95% confidence interval, 1.14-1.62). Survey responses and comments were positive. CONCLUSIONS: This pilot integration of BH showed significant improvements in treatment initiation and other measures. Strengths of Lean analysis included workflow improvement, system perspective, and project success. Further evaluation is indicated.

It's About Time for Autism Reform Legislation in Utah.

On 3 April 2014, Governor Gary Herbert signed into law a health insurance reform bill that requires private insurers to cover autism therapy. Specifically, SB57 requires state-regulated health plans to cover applied behavior analysis (ABA) therapy. While early diagnosis and intervention can reduce the long-term cost of autism, families are finding themselves bankrupt in order to pay for ABA therapy. Currently, 37 states, and the District of Columbia have enacted insurance reform laws. Ensuring that children with autism receive proper therapy is a serious public health issue. Utah was right to pass reform legislation because it properly benefits and safeguards the interests of affected children in promoting their well-being and participation in society.

US state variation in autism insurance mandates: balancing access and fairness.

This article examines how nations split decision-making about health services between federal and sub-federal levels, creating variation between states or provinces. When is this variation ethically acceptable? We identify three sources of ethical acceptability-procedural fairness, value pluralism, and substantive fairness-and examine these sources with respect to a case study: the fact that only 30 out of 51 US states or territories passed mandates requiring private insurers to offer extensive coverage of autism behavioral therapies, creating variation for privately insured children living in different US states. Is this variation ethically acceptable? To address this question, we need to analyze whether mandates go to more or less needy states and whether the mandates reflect value pluralism between states regarding government's role in health care. Using time-series logistic regressions and data from National Survey of Children with Special Health Care Needs, Individual with Disabilities Education Act, legislature political composition, and American Board of Pediatrics workforce data, we find that the states in which mandates are passed are less needy than states in which mandates have not been passed, what we call a cumulative advantage outcome that increases between-state disparities rather than a compensatory outcome that decreases between-state disparities. Concluding, we discuss the implications of our analysis for broader discussions of variation in health services provision.

Changing life jacket wearing behavior: an evaluation of two approaches.

In the United States during 1999-2012, about 4 per cent of adults wore life jackets while engaged in recreation on powerboats. Educational campaigns have promoted life jacket use. Mandatory use regulations target primarily children or boaters on personal watercrafts or water skiing. We describe findings from two interventions - 'Wear It California!', a targeted marketing campaign in the California Delta region and mandatory wear regulations at four US Army Corps of Engineers (USACE) lakes in the state of Mississippi. Before the campaign in the Delta, adult wear was 8.5 per cent, increasing to 12.1 per cent during the first year, dipping to 9.4 per cent during the second year, and rising slightly to 10.5 per cent 3 plus years after the campaign. Before mandatory regulations at USACE lakes, adult wear was 13.7 per cent, increasing to 75.6 per cent during the first year, 70.1 per cent during the second year, and remaining high at 68.1 per cent in the third year. Policymakers should consider these findings when choosing how to increase life jacket use.

Ethical dilemmas in social work practice with disabled people: the use of physical restraint.

This article discusses the use of restraint with disabled adults and children and uses a case study of one particular child to explore issues related to the use of restraint, including the consent of the person subjected to restraint, their human rights, and the balancing of these rights with the need to reduce the risk of harm. The case study involves a young woman who requested to be restrained in a particular way and the challenges this posed to the staff caring for her. The article concludes that in many complex situations there is no clearly right approach to take, and each situation involving restraint must be considered on an individual case-by-case basis.

Conditional rights, benefit reform, and drug users: reducing dependency?

United Kingdom government policy to increase social security claimants' entry to the labour market through conditions attached to unemployed, sickness and incapacity benefits now includes additional measures to activate particular groups such as lone parents and drug users. The latter are a prime target because of their high level of dependency on benefits and because social security rules are seen as having the potential to modify the behaviour of individuals with a lifestyle regarded as being at odds with the moral obligations of citizenship and incompatible with the government's realization of its wider economic and social goals. There are strict procedures for the identification of drug-user claimants, enabling additional conditions to be attached to their benefit rights. This article discusses the general trend in benefit reform towards increased conditionality and evaluates the reforms affecting drug users, considering human rights and other implications. It concludes by reflecting on the status of conditional rights to social security as social rights.

[Training of dogs--legal assessment of the use of electric collars]. / Ausbildung von Hunden--Rechtliche Bewertung des Einsatzes von Elektroreizgeräten.

The use of an electric collar for training dogs is fundamentally forbidden. The verdict of the Federal German Administrative Court dated February 23, 2006 (ref. 3 C 14.05) provides legal clarity and indicates the approach to be taken to enable exceptions from the fundamental ban on electric collars. It is particularly to prevent the misuse of electric collars in the interests of animal welfare that federal legislation should further develop the approach specified in 1998 by including Article 3, No. 11 of the German act on the prevention of cruelty to animals (TierSchG). In this context, it is recommended to continue intensive specialist debate on the question of whether and, where applicable, to what extent the use of electric collars may be permitted, e.g. within the context of training dogs.

Pushing the employment agenda: case study research of high performing States in integrated employment.

Organizational variables, including policies, practices, collaborations, and funding mechanisms resulting in high performance in integrated employment, were described through case study research in 3 states. Findings address how contextual factors, system-level strategies, and goals of the system are related as well as how they sustain systems change. Strategies such as flexibility in funding and practices; communication of values through data, rewards, and funding incentives; and innovation diffusion through relationships and training were most successful when they were embedded within the context of a solid values base, a network of dedicated stakeholders, and clarity about systemic goals. Implications are presented with respect to state systems, community rehabilitation providers as partners in planning, and future leadership in the field.

Evaluating two brief substance-use interventions for mandated college students.

OBJECTIVE: This study evaluated two brief personal feedback substance-use interventions for students mandated to the Rutgers University Alcohol and Other Drug Assistance Program for Students (ADAPS): (1) a brief motivational interview (BMI) intervention and (2) a written feedback-only (WF) intervention. A key question addressed by this study was whether there is a need for face-to-face feedback in the context of motivational interviewing to affect changes in substance-use behaviors or whether a written personal feedback profile is enough of an intervention to motivate students to change their substance use. METHOD: The sample consisted of 222 students who were mandated to ADAPS, were eligible for the study, and completed the 3-month follow-up assessment. Eligible students completed a baseline assessment from which a personal feedback profile was created. They were then randomly assigned to the BMI or WF condition. Students were followed 3 months later. RESULTS: Students in both interventions reduced their alcohol consumption, prevalence of cigarette and marijuana use, and problems related to alcohol and drug use between baseline and follow-up. There were no differences between the two intervention conditions in terms of any substance-use outcomes. CONCLUSIONS: The results suggest that, under these circumstances and with these students, assessment and WF students changed similarly to those who had an assessment and WF within the context of a BMI. Given the fact that the former is less costly in terms of time and personnel, written profiles may be found to be a cost-effective means of reducing alcohol and drug use and related problems among low- to moderate-risk mandated college students. More research is needed with mandated students to determine the efficacy of feedback interventions and to isolate the effects of interventions from the effects of being caught and being reprimanded to treatment.

Contrasting jail diversion and in-jail services for mental illness and substance abuse: do they serve the same clients?

Baseline data from a study of jail diversion services and in-jail behavioral health services were used to examine the differences in clients served by these two models of responding to people with co-occurring mental health and substance abuse problems in the criminal justice system. Clients of the diversion service had more acute psychiatric symptoms and were more likely to have a diagnosis of psychosis NOS. Clients of the in-jail service were more likely to have been on probation or parole in the past and to have received substance abuse treatment. Different service models may attract and serve different populations of clients. Diversion services may cast a wider net that includes clients who may not have otherwise been involved in forensic services.

An analysis of post-booking jail diversion programming for persons with co-occurring disorders.

For persons with co-occurring disorders, interaction with criminal justice systems is a frequent occurrence. As a result, a variety of diversionary programs have been developed nationwide. In this study, a total of 248 individuals with co-occurring disorders of serious mental illness and substance use disorders who had been arrested and booked on misdemeanor charges participated in a post-booking jail diversion program in two urban communities. A quasi-experimental design was used with individuals assigned to diversion or non-diversion status based upon the decision processes of the mental health-criminal justice systems. The effectiveness of the jail diversion program was evaluated from a variety of sources, including structured interviews, behavioral health service utilization patterns, and criminal justice recidivism patterns. Analyses revealed general main effects for time on many of the outcome variables, with few main effects or interaction effects detected on the basis of diversion status (diverted versus non-diverted). Across all measures assessing mental health and substance abuse, study participants displayed improvements over time, irrespective of their diversion status or program location. Participants generally displayed no significant changes in their rates of accessibility to, or frequency of use of, the various mental health, substance abuse, and other services, and few changes for diversion status were detected with regard to service utilization. Although a number of indicators of criminality and violence were reduced over time, these reductions were statistically insignificant, with changes for diversionary status or time identified at follow-up. These results are discussed in light of their implications for jail diversion programming and future research in this area.

Challenges to the use of nonpharmacologic interventions in nursing homes.

The Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987, stated that nursing homes should try nonpharmacologic interventions before resorting to pharmacologic agents when addressing problem behaviors among residents. Since that time, the use of pharmacologic agents has decreased, but there is little evidence to suggest that the use of nonpharmacologic interventions has increased. Psychosocial models describe problem behaviors as complex phenomena that require individualized strategies based on a resident's unique characteristics. Categories of intervention include social contact, behavior therapy, staff training, structured activities, environmental interventions, and a combination of therapies. This article discusses internal barriers to the use of nonpharmacologic interventions based on the Porras stream organization model: organizing arrangements, social factors, technology, and physical setting. Also, external barriers related to the regulatory, legal, and economic sectors are discussed. The authors offer recommendations for overcoming these barriers.