After The Demonstration: What States Sustained After the End of Federal Grants to Improve Children's Health Care Quality.

Introduction Under the CHIPRA Quality Demonstration Grant Program, CMS awarded $100 million through 10 grants that 18 state Medicaid agencies implemented between 2010 and 2015. The program's legislatively-mandated purpose was to evaluate promising ideas for improving the quality of children's health care provided through Medicaid and CHIP. As part of the program's multifaceted evaluation, this study examined the extent to which states sustained key program activities after the demonstration ended. Methods We identified 115 potentially sustainable elements within states' CHIPRA demonstrations and analyzed data from grantee reports and key informant interviews to assess sustainment outcomes and key influential factors. We also assessed sustainment of the projects' intellectual capital. Results 56% of potentially sustainable elements were sustained. Sustainment varied by topic area: Elements related to quality measure reporting and practice facilitation were more likely to be sustained than others, such as parent advisors. Broad contextual factors, the state's Medicaid environment, implementation partners' resources, and characteristics of the demonstration itself all shaped sustainment outcomes. Discussion Assessing sustainment of key elements of states' CHIPRA quality demonstration projects provides insight into the fates of the "promising ideas" that the grant program was designed to examine. As a result of the federal government's investment in this grant program, many demonstration states are in a strong position to extend and spread specific strategies for improving the quality of care for children in Medicaid and CHIP. Our findings provide insights for policymakers and providers working to improve the quality of health care for low income children.

State Variation in the Delivery of Comprehensive Services for Medicaid Beneficiaries with Schizophrenia and Bipolar Disorder.

Medicaid beneficiaries with schizophrenia and bipolar disorder require a range of services and supports. This descriptive study used 2007 Medicaid claims data from 21 states and the District of Columbia to examine the extent to which this population received guideline-concordant medications, medication monitoring, outpatient mental health care, and preventive physical health care. More than 80 % of beneficiaries in each state filled at least one prescription for a guideline-concordant medication during the year but, on average, only 57 % of those with schizophrenia and 45 % of those with bipolar disorder maintained a continuous supply of medications. Roughly 25 % did not have an outpatient mental health visit during the year (excluding case management and some other services); in some states more than half did not have such a visit. Only 11 % of beneficiaries received a physical health examination or health behavior counseling when claims codes were used to identify these services rather than all primary care physician visits. Less than 5 % of beneficiaries maintained their supply of medications, received medication monitoring and had an outpatient mental health visit, physical health examination or received health behavior counseling during the year. Although these rates of service utilization are likely conservative and the data predate recent efforts to integrate care, the findings underscore the need for quality improvement efforts targeted to this population and may provide a baseline for monitoring progress.

The Effectiveness of a Peer-Staffed Crisis Respite Program as an Alternative to Hospitalization.

OBJECTIVE: This study assessed whether peer-staffed crisis respite centers implemented in New York City in 2013 as an alternative to hospitalization reduced emergency department (ED) visits, hospitalizations, and Medicaid expenditures for individuals enrolled in Medicaid. METHODS: This study used Medicaid claims and enrollment data for January 2009 through April 2016 to estimate impacts on ED visits, hospitalizations, and total Medicaid expenditures by using a difference-in-differences model with a matched comparison group. The study sample included 401 respite center clients and 1,796 members of the comparison group. RESULTS: In the month of crisis respite use and the 11 subsequent months, Medicaid expenditures were on average $2,138 lower per Medicaid-enrolled month and there were 2.9 fewer hospitalizations for crisis respite clients than would have been expected in the absence of the intervention (p<.01). CONCLUSIONS: Peer-staffed crisis respite services resulted in lowered rates of Medicaid-funded hospitalizations and health expenditures for participants compared with a comparison group. The findings suggest that peer-staffed crisis respites can achieve system-level impacts.

Care coordination for children with special needs in Medicaid: lessons from Medicare.

OBJECTIVES: To provide actionable recommendations for improving care coordination programs for children with special healthcare needs (CSHCN) in Medicaid managed care. STUDY DESIGN: Literature review and interviews with stakeholders and policy experts to adapt lessons learned from Medicare care coordination programs for CSHCN in Medicaid managed care. METHODS: We reviewed syntheses of research on Medicare care coordination programs to identify lessons learned from successful programs. We adapted findings from Medicare to CSHCN in Medicaid based on an environmental scan and discussions with experts. The scan focused on Medicaid financing and eligibility for care coordination and how these intersect with Medicaid managed care. The expert discussions included pediatricians, Medicaid policy experts, Medicaid medical directors, and a former managed care executive, all experienced in care coordination for CSHCN. RESULTS: We found 6 elements that are consistently associated with improved outcomes from Medicare care coordination programs and relevant to CSHCN in Medicaid: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators' expertise with that of other clinical experts. CONCLUSIONS: States and Medicaid managed care organizations have many options for designing effective care coordination programs for CSHCN. Their choices should account for the diversity of conditions among CSHCN, families' capacity to coordinate care, and social determinants of health.

Implementing a Whole Health Model in a Community Mental Health Center: Impact on Service Utilization and Expenditures.

OBJECTIVE: This study examined whether implementing a whole health care model in a community mental health center reduced the use of acute care services and total Medicare expenditures. The whole health care model embedded monitoring of overall health and wellness education within the center's outpatient mental and substance use disorder treatment services, and it improved care coordination with primary care providers. METHODS: This study used fee-for-service Medicare administrative claims and enrollment data for June 2009 through July 2015 for the intervention (N=846) and matched comparison group (N=2,643) to estimate a difference-in-differences model. RESULTS: For the first two-and-a-half years of the program, Medicare expenditures decreased by $266 per month on average for each enrolled beneficiary in the intervention group relative to the comparison group (p<.01). Intervention clients had .02 fewer hospitalizations, .03 fewer emergency department (ED) visits, and .13 fewer office visits per month relative to the comparison group (p<.05 for all estimates). CONCLUSIONS: Overall, the whole health model reduced Medicare expenditures, ED visits, and hospitalization rates. These results may be due in part to the availability of more comprehensive medical data and staff's improved awareness of client's overall health needs. There was a lag between initial program implementation and the program's substantial impact on health expenditures. This lag may be attributed to the substantial transformation and time needed for staff to adapt to the program.

A national survey of state licensing, regulating, and monitoring of residential facilities for children with mental illness.

OBJECTIVE: Little national information is available to help policy makers understand the methods that states use to regulate residential facilities for children with mental illness. This article describes the results of a government-sponsored survey of state officials that examined how states license, regulate, and monitor such facilities. METHODS: Questionnaires were mailed to selected officials in each of the 50 states and the District of Columbia, followed by extensive telephone and e-mail contacts. Questionnaire items covered program characteristics, licensing and accreditation, mandated services, monitoring and oversight methods, and payment sources. RESULTS: Information was gathered on 71 types of residential facilities in 38 states, accounting for 3,628 separate residential facilities with 50,507 beds as of September 30, 2003. States differed widely in the types of residential facilities that they regulate and their mix of regulatory methods, which included requirements for announced and unannounced visits, mandated staff-to-client ratios, minimum levels of education for facility directors, specifications for licensing practices and critical incident reporting, mandated complaint review procedures, and accreditation from designated organizations. Welfare, mental health, and health departments all participated in regulating facilities. CONCLUSIONS: States relied on at least several regulatory methods, but no state used all of the possible methods. The regulatory environment is complex in most states because several agencies are involved in licensing, regulating, and reviewing complaints. To ensure that residential facilities effectively address the needs of children with mental illness and their families, policy makers should review and improve their state's data on methods for regulating residential facilities.

Primary Care Physicians' Experiences With and Attitudes Toward Pediatric Quality Reporting.

OBJECTIVE: To assess primary care providers' experiences with and attitudes toward pediatric-focused quality reports and identify key associated physician/practice characteristics. METHODS: We performed a cross-sectional survey of pediatricians and family physicians providing primary care to publicly insured children in 3 states (North Carolina, Ohio, Pennsylvania). The survey included questions about receipt of pediatric quality reports, use of reports for quality improvement (QI), and beliefs about the effectiveness of reports for QI. We used multivariable analyses to assess associations between responses and physician/practice characteristics, including exposure to federally funded demonstration projects aimed at increasing quality reporting to physicians serving publicly insured children. We supplemented these analyses with a thematic investigation of data from 46 interviews with physicians, practice staff, and state demonstration staff. RESULTS: Seven hundred twenty-seven physicians responded to the survey (overall response rate: 45.2%). Most physicians were receiving quality reports related to pediatric care (79.8%; 95% confidence interval [CI], 77.2%-82.4%) and believed that quality reports can be effective in helping guide QI (70.5%; 95% CI, 67.5%-73.5%). Fewer used quality reports to guide QI efforts (32.5%; 95% CI, 29.5%-35.6%). There were no significant associations between demonstration exposure and experiences or attitudes. Interview data suggested that physicians were receptive to quality reporting, but significant barriers remain to using such reports for QI, such as limited staff time or training in QI. CONCLUSIONS: Although pediatric quality reporting is considered a promising strategy, in this study, state efforts appeared insufficient to overcome the barriers to using reports to guide practice-based QI.

Associations between practice-reported medical homeness and health care utilization among publicly insured children.

BACKGROUND: The patient-centered medical home (PCMH) is widely promoted as a model to improve the quality of primary care and lead to more efficient use of health care services. Few studies have examined the relationship between PCMH implementation at the practice level and health care utilization by children. Existing studies show mixed results. METHODS: Using practice-reported PCMH assessments and Medicaid claims from child-serving practices in 3 states participating in the Children's Health Insurance Program Reauthorization Act of 2009 Quality Demonstration Grant Program, this study estimates the association between medical homeness (tertiles) and receipt of well-child care and nonurgent, preventable, or avoidable emergency department (ED) use. Multilevel logistic regression models are estimated on data from 32 practices in Illinois (IL) completing the National Committee for Quality Assurance's (NCQA) medical home self-assessment and 32 practices in North Carolina (NC) and South Carolina (SC) completing the Medical Home Index (MHI) or Medical Home Index-Revised Short Form (MHI-RSF). RESULTS: Medical homeness was not associated with receipt of age-appropriate well-child visits in either sample. Associations between nonurgent, preventable, or avoidable ED visits and medical homeness varied. No association was seen among practices in NC and SC that completed the MHI/MHI-RSF. Children in practices in IL with the highest tertile NCQA self-assessment scores were less likely to have a nonurgent, preventable, or avoidable ED visit than children in practices with low (odds ratio 0.65; 95% confidence interval 0.47-0.92; P < .05) and marginally less likely to have such a visit compared with children in practices with medium tertile scores (odds ratio 0.72, 95% confidence interval 0.52-1.01; P = .06). CONCLUSIONS: Higher levels of medical homeness may be associated with lower nonurgent, preventable, or avoidable ED use by publicly insured children. Robust longitudinal studies using multiple measures of medical homeness are needed to confirm this observation.

A randomized, controlled trial of a community-based support program for families of children with chronic illness: pediatric outcomes.

BACKGROUND: Children with chronic illnesses have a heightened risk for mental health problems. OBJECTIVES: To develop, implement, and evaluate child outcomes of a 15-month, community-based, family-support intervention designed to reduce risk for poor adjustment and mental health problems in children with 1 of 4 chronic illnesses (diabetes mellitus, sickle cell anemia, cystic fibrosis, or moderate to severe asthma) and their mothers. DESIGN: Randomized, controlled clinical trial design with multiple measures of mental health based on both child and parent reports taken 1 year apart. SETTING: Community-based intervention linked to subspecialty and general pediatric clinics and practices in Baltimore, Md. PARTICIPANTS: One hundred thirty-six mothers and children aged 7 to 11 years with diabetes mellitus, sickle cell anemia, cystic fibrosis, or moderate to severe asthma. INTERVENTION: The program, provided by "experienced mothers" and child life specialists, included telephone contacts, face-to-face visits, and special family events. MAIN OUTCOME MEASURES: Outcomes were measured using the following instruments: the Personal Adjustment and Role Skills Scale III, the Children's Depression Inventory, the Revised Children's Manifest Anxiety Scale, and the Self-Perception Profile for Children. RESULTS: The experimental group's mean adjustment score increased over the intervention period while the control group's mean adjustment score decreased. Analysis of variance demonstrated that the intervention had a significant main effect on postintervention adjustment controlling for baseline scores (P =.01). Using a cutoff score indicating maladjustment, the percentage of experimental group children in the maladjustment range fell from 19% at baseline to 10% after the intervention; the percentage of control group children in the maladjustment range rose from 15% at baseline to 21% after the intervention. The effect of the intervention was more pronounced for children who had low physical self-esteem than for those who had moderate to high physical self-esteem at the beginning of the program. CONCLUSIONS: Our results demonstrate modest positive effects of a family support intervention in promoting the adjustment of children with selective chronic health conditions. Including child life specialists in a community-based intervention may be especially salient for children with chronic illnesses who have low physical self-esteem. The intervention had a similar outcome for all diagnostic groups, suggesting that it could be effective for children with any chronic illness and implemented in a variety of pediatric settings.

Medicaid managed care and working-age beneficiaries with disabilities and chronic illnesses.

Even after a decade of study, there are still many questions about how working-age adults with disabilities or chronic illnesses are faring in Medicaid managed care. This article draws from recent research to examine two critical issues: the need for better outcome measures specific to this population and the importance of evaluations that accurately estimate program effects, despite continued policy change, considerable differences among States, and extreme population diversity. The authors outline a research agenda that will help policymakers develop a more precise sense of how managed care practices affect different subgroups of working-age adults with disabilities and chronic illnesses and how practices could be altered to improve Medicaid's ability to meet their needs.

Early interventions to prevent disability for workers with mental health conditions: impacts from the DMIE.

BACKGROUND: As of 2011, over 9 million working-age adults were receiving federal disability benefits and this number is expected to rise steadily. Early intervention programs that seek to maintain employment and forestall the receipt of federal disability benefits offer a promising strategy to reduce the growing number of working-age adults on the disability rolls. OBJECTIVES: Using random assignment, this study examined whether an early intervention program of personal navigators, enhanced medical care, and employment supports can reduce dependence on federal disability benefits for adult workers with mental health conditions. METHODS: The study reports multivariate and descriptive findings based on 2279 participants in the Demonstration to Maintain Independence and Employment (DMIE). Logistic regression analysis was used to estimate program impacts in the treatment group relative to the control group. Data were integrated from state participant surveys and the SSA Ticket Research File. RESULTS: The DMIE intervention significantly reduced the percent of participants who received disability benefits after 12 months of enrollment. Across both states, the difference between the treatment group and control group was 1.1 percentage points (2.5% versus 3.6%, p < 0.01). In Texas, the difference was 1.2 percentage points (3.2% versus 4.4%, p < 0.01). CONCLUSIONS: Early intervention programs with a personal navigator can reduce dependence on federal disability benefits for adult workers with mental health conditions. Future studies on the cost-effectiveness of such programs are needed.

State and demographic variation in use of depot antipsychotics by Medicaid beneficiaries with schizophrenia.

OBJECTIVE: This study examined state and demographic variation in use of depot antipsychotics among Medicaid beneficiaries with schizophrenia. METHOD: Medicaid claims data (2007) from 21 states and the District of Columbia were analyzed for 102,884 beneficiaries age 18 to 64 with schizophrenia. Rates of receipt of depot antipsychotics were determined for all beneficiaries and for African Americans, Caucasians, and beneficiaries from "all other races." RESULTS: Across study states, a mean of 10% of beneficiaries with schizophrenia received depot antipsychotics. Rates ranged from 1.9% in the District of Columbia to 20.9% in Alabama. In 12 states, African Americans were disproportionately likely to receive these medications compared with beneficiaries of other races. CONCLUSIONS: Use of depot antipsychotics varied across state Medicaid programs. African Americans received a disproportionate share in many states. Further research is needed to understand the sources of such variation. These findings underscore the need to monitor the use of depot antipsychotics.

Medication continuity among Medicaid beneficiaries with schizophrenia and bipolar disorder.

OBJECTIVE: This study was conducted to examine whether medication continuity among Medicaid beneficiaries with schizophrenia and bipolar disorder was associated with medication utilization management practices (prior authorization, copayment amounts, and refill and pill quantity limits), managed care enrollment, and other state and beneficiary characteristics. METHODS: With 2007 Medicaid Analytic Extract claims data from 22 states, random-effects logistic regression modeled the odds of high medication continuity, defined as receiving medications for at least 80% of the days enrolled in Medicaid, among beneficiaries ages 18-64 with a diagnosis of schizophrenia (N=91,451) or bipolar disorder (N=33,234). RESULTS: Sixty-four percent of beneficiaries with schizophrenia and 54% of beneficiaries with bipolar disorder had high medication continuity. Medication continuity was worse among beneficiaries with schizophrenia in states that required prior authorization for antipsychotics, $2-$3 copayments for generic medications, or $1 copayments for branded medications (compared with no copayments). For beneficiaries with bipolar disorder, medication continuity was worse among those in states with more prior-authorization requirements for different classes of medications or $1 copayments for branded medications. Medication continuity was worse among beneficiaries who were African American, Hispanic, younger, or enrolled in a health maintenance organization health plan or who had a comorbid substance use disorder or cardiovascular disease. CONCLUSIONS: Prior-authorization requirements and copayments for medications may present barriers to refilling medications for Medicaid beneficiaries with schizophrenia or bipolar disorder. State Medicaid programs should consider the unintended consequences of medication utilization management practices for this population.

Seclusion and restraint practices in residential treatment facilities for children and youth.

Policymakers, advocates, and families remain concerned about the use of seclusion and restraint in residential treatment facilities for children and youth. This study used data from 2 national surveys to examine the extent to which residential treatment facilities consistently implement certain practices following incidents of seclusion or restraint. The study found that 76% of facilities reported having secluded or restrained youth in the previous year; 34% of these facilities reported that, following such incidents, they always debrief the youth, family, and staff; notify the attending physician; and record the incident in the treatment plan. Accredited facilities and those that conduct a trauma assessment upon admission were more than twice as likely as others to consistently implement these practices. States and providers should continue to monitor seclusion and restraint practices and identify opportunities for quality improvement.

Effects of a discharge planning program on Medicaid coverage of state prisoners with serious mental illness.

OBJECTIVE: Many inmates with serious mental illness leave prisons without health insurance, which reduces their access to health care and therefore places them at risk of relapse and rearrest. This study assessed the effectiveness of a discharge planning program implemented in three Oklahoma state prisons to assist inmates with serious mental illness to enroll in Medicaid on the day of release or soon thereafter. METHODS: Administrative data containing demographic characteristics, Medicaid enrollment status, and mental health service use were collected for 686 inmates with serious mental illness released from Oklahoma state prisons between 2004 and 2008. Regression-adjusted difference-in-difference estimates were used to compare postrelease Medicaid enrollment and service use of 77 inmates eligible for program services with those of inmates with mental illness of similar severity in three comparison groups. RESULTS: In facilities implementing the program, the percentage of inmates with serious mental illness who enrolled in Medicaid on the day of release increased from 8% during the baseline period to 25% after program implementation. The difference-in-difference estimates, which adjusted for trends in Medicaid enrollment and inmate demographic and prison stay characteristics, indicated that the program increased Medicaid enrollment by 15 percentage points (p=.012) and increased Medicaid mental health service use by 16 percentage points (p=.009). CONCLUSIONS: Although additional research is needed to assess the program's long-term effects on health care utilization and rearrest, this study illustrated that with careful planning, interagency collaboration, and dedicated staff, states can successfully increase Medicaid coverage among inmates with serious mental illness on their release from prison.

Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states, 2003.

OBJECTIVE: This study identified Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003 (N=1,380,190) and examined their use of medical services. METHODS: Administrative and fee-for-service claims data from Medicaid Analytic eXtract files were analyzed to identify mutually exclusive groups of beneficiaries who used either mental health or substance abuse services and to describe patterns of medical service use. RESULTS: Overall, 11.7% of Medicaid beneficiaries were identified as using mental health or substance abuse services (10.9% and .7% used each of these services, respectively), with substantial variation across age and eligibility groups. Among beneficiaries using mental health services, 47.4% had visited an emergency room for any reason, 7.8% were treated for their disorder in inpatient settings, 13.8% received inpatient treatment for problems other than their mental or substance use disorders, and 70.4% received prescriptions for psychotropic medications. Among beneficiaries using substance abuse services, 60.7% had visited an emergency room, 12.6% were treated for their disorder in inpatient settings, 24.7% received other inpatient treatment, and 46.1% received prescriptions for psychotropic medications. Among beneficiaries not using either mental health or substance use services, 29.0% had visited an emergency room, 12.7% received inpatient treatment, and 10.1% received prescriptions for psychotropic medications. CONCLUSIONS: Beneficiaries who used mental health or substance abuse services entered general inpatient settings and visited emergency rooms more frequently than other beneficiaries.

The therapeutic relationship in child therapy: perspectives of children and mothers.

Examined qualities of the therapeutic relationship as perceived by low-income children who were in treatment for serious emotional disorders and their mothers. Recent emphasis on engaging families in the treatment of their children highlights the importance of understanding processes that facilitate therapeutic partnerships. Therapeutic bonds (i.e., the closeness of the relationship to therapist) for both children and their mothers were assessed. One-hundred fifty-seven families participated. Cross-sectional analyses indicated that children's perceptions of closeness with their therapists were associated with their perceptions of closeness with their mothers, their own age, and welfare status of the family. Maternal therapy bond scores were associated with mental health services efficacy and breadth of social support.