Determinants of remote measurement-based care uptake in a safety net outpatient psychiatry department as part of learning health system transition.

Introduction: Behavioral measurement-based care (MBC) can improve patient outcomes and has also been advanced as a critical learning health system (LHS) tool for identifying and mitigating potential disparities in mental health treatment. However, little is known about the uptake of remote behavioral MBC in safety net settings, or possible disparities occurring in remote MBC implementation. Methods: This study uses electronic health record data to study variation in completion rates at the clinic and patient level of a remote MBC symptom measure tool during the first 6 months of implementation at three adult outpatient psychiatry clinics in a safety net health system. Provider-reported barriers to MBC adoption were also measured using repeated surveys at one of the three sites. Results: Out of 1219 patients who were sent an MBC measure request, uptake of completing at least one measure varied by clinic: General Adult Clinic, 38% (n = 262 of 696); Substance Use Clinic, 28% (n = 73 of 265); and Transitions Clinic, 17% (n = 44 of 258). Compared with White patients, Black and Portuguese or Brazilian patients had lower uptake. Older patients also had lower uptake. Spanish language of care was associated with much lower uptake at the patient level. Significant patient-level disparities in uptake persisted after adjusting for the clinic, mental health diagnoses, and number of measure requests sent. Providers cited time within visits and bandwidth in their workflow as the greatest consistent barriers to discussing MBC results with patients. Conclusions: There are significant disparities in MBC uptake at the patient and clinic level. From an LHS data infrastructure perspective, safety net health systems may need to address the need for possible ways to adapt MBC to better fit their populations and clinical needs, or identify targeted implementation strategies to close data gaps for the identified disparity populations.

Assessing the Long-Term Effectiveness of a Behavioral Health Home for Adults With Bipolar and Psychotic Disorders.

OBJECTIVE: This study aimed to examine the impact of a behavioral health home (BHH) to better understand its potential to improve health for individuals with serious mental illness. METHODS: Propensity score-weighted interrupted time series analysis was used to estimate service utilization and chronic disease management through 3.5 years after BHH implementation and to compre BHH enrollees (N=413) with other patients with serious mental illness in the same health system (N=1,929). RESULTS: Relative to control group members, BHH patients had an immediate increase in primary care visits (+0.18 visits/month), which remained higher throughout follow-up, and an immediate decrease in emergency department visits (-0.031 visits/month). Behavioral health outpatient visits, which were increasing for BHH participants before implementation, began decreasing postimplementation; this decrease (-0.016 visits/month) was significantly larger than for the control group. Inpatient and outpatient visits for general medical health were decreasing over time for both groups before implementation but decreased more slowly for BHH patients postimplementation. Although behavioral health inpatient visits decreased for both groups around the start of the BHH program and remained lower, this initial drop was larger for the non-BHH group. BHH participation was associated with decreases in hemoglobin A1c values but no shift in low-density lipoprotein cholesterol values. CONCLUSIONS: The results reflect the challenges of improving health for patients with serious mental illness, even as access to primary care is increased. Further study is needed about which complex interventions inside and outside of the health care system can help offset the 20- to 30-year mortality gap faced by this population.

Care Management for Serious Mental Illness: A Systematic Review and Meta-Analysis.

OBJECTIVE: Persons with serious mental illness face adverse psychiatric and medical outcomes, and their care is associated with a large burden of health care costs. Care management, in which assessment, care planning, and care coordination are provided, is a common model of support, yet the evidence supporting its use among psychiatric populations is mixed. A systematic review and a meta-analysis were undertaken to determine the impact of care management on clinical outcomes, acute care utilization, cost, and satisfaction among adults with serious mental illness. METHODS: A multidatabase literature search was performed. Articles were included if they compared standard outpatient care plus care management with standard outpatient care alone for adults with serious mental illness and reported on one or more predefined outcomes. Randomized controlled trials (RCTs) and other study designs were permitted for inclusion in the systematic review. The meta-analysis included only RCTs. RESULTS: For the systematic review, 34 articles representing 28 unique studies were included. Fifteen of these articles, representing 12 unique studies, were included in the meta-analysis, which indicated that care management was associated with small, statistically significant improvements in psychiatric symptoms, overall quality of life (QOL), and mental QOL (Hedges' g range 0.13-0.26). In addition, care management was associated with a small, statistically significant reduction in inpatient psychiatric hospital days (Hedges' g=0.16, p=0.02). CONCLUSIONS: Care management is associated with fewer psychiatric symptoms and greater QOL for persons with serious mental illness. Further work is needed to determine which components of the intervention are associated with effectiveness.

Changes in Psychiatric Emergency Room Visits Following the Boston Marathon Bombing.

OBJECTIVE: This study reviews patient encounters at a Boston-area community hospital Psychiatric Emergency Services (PES) following the Boston Marathon bombings, with the goal of describing the impact of terrorist attacks on PES encounters. METHODS: All PES encounters for 2 months preceding and 2 months following the bombing were identified in the electronic medical record. Demographics, current and past psychiatric problems, and trauma history were assessed for all records. Encounters seen post-bombing were compared with those before the bombing. RESULTS: Demographics, current and past psychiatric problems, and trauma history were not significantly different before versus after the bombing; 36 of 440 (8.2%) post-bombing encounters directly mentioned the bombings. New-onset posttraumatic stress disorder (PTSD) symptoms caused by the bombing occurred in only 4 encounters (0.9%). CONCLUSIONS: PES encounters after a terrorist event are likely to mirror those seen before a terrorist event, with only a minority of encounters presenting for new PTSD or acute stress disorder.

The employment intervention demonstration program: major findings and policy implications.

This article summarizes the published results of the Employment Intervention Demonstration Program (EIDP), a federally-funded, multi-site study examining the effectiveness of supported employment programs for 1273 unemployed individuals with psychiatric disabilities in the U.S. Findings confirm the effectiveness of supported employment across different models, program locations, and participant populations. The study's results are discussed in the context of public policies designed to encourage return to work for those with a severe mental illness.

Mind the Gap: Developing an Integrated Behavioral Health Home to Address Health Disparities in Serious Mental Illness.

OBJECTIVE: This study evaluated the impact of an integrated behavioral health home (BHH) pilot on adults with psychotic and bipolar disorders. METHODS: Quasi-experimental methods were used to compare outcomes before (September 2014-August 2015) and after the intervention (September 2015-August 2016) among ambulatory BHH patients and a control group. Electronic health records were compared between 424 BHH patients (N=369, psychotic disorder; N=55, bipolar disorder) and 1,521 individuals from the same urban, safety-net health system who were not enrolled in the BHH. Groups were weighted by propensity score on the basis of sex, age, race-ethnicity, language, 2010 U.S. Census block group characteristics, Medicare and Medicaid enrollment, and diabetes diagnosis. RESULTS: BHH patients had fewer total psychiatric hospitalizations and fewer total emergency visits compared with the control group, a difference that was predominantly driven by patients with at least one psychiatric hospitalization or ED visit. There were no differences in medical hospitalizations. Although BHH patients were more likely to receive HbA1c screening, there were no differences between the groups in lipid monitoring. Regarding secondary outcomes, there were no significant differences in changes in metabolic monitoring parameters among patients with diabetes. CONCLUSIONS: Participation in a pilot ambulatory BHH program among patients with psychotic and bipolar disorders was associated with significant reductions in ED visits and psychiatric hospitalizations and increased HbA1c monitoring. This evaluation builds on prior research by specifying intervention details and the clinical target population, strengthening the evidence base for care integration to support further program dissemination.

Results of a multisite randomized trial of supported employment interventions for individuals with severe mental illness.

CONTEXT: National probability surveys indicate that most individuals with schizophrenia and other severe mental illnesses are not employed. This multisite study tested the effectiveness of supported employment (SE) models combining clinical and vocational rehabilitation services to establish competitive employment. METHODS: We randomly assigned 1273 outpatients with severe mental illness from 7 states in the United States to an experimental SE program or to a comparison or a services-as-usual condition, with follow-up for 24 months. Participants were interviewed semiannually, paid employment was tracked weekly, and vocational and clinical services were measured monthly. Mixed-effects random regression analysis was used to predict the likelihood of competitive employment, working 40 or more hours in a given month, and monthly earnings. RESULTS: Cumulative results during 24 months show that experimental group participants (359/648 [55%]) were more likely than those in the comparison programs (210/625 [34%]) to achieve competitive employment (chi(2) = 61.17; P<.001). Similarly, patients in experimental group programs (330/648 [51%]) were more likely than those in comparison programs (245/625 [39%]) to work 40 or more hours in a given month (chi(2) = 17.66; P<.001). Finally, participants in experimental group programs had significantly higher monthly earnings than those in the comparison programs (mean, US 122 dollars/mo [n=639] vs US 99 dollars/mo [n=622]); t(1259) = -2.04; P<.05). In the multivariate longitudinal analysis, experimental condition subjects were more likely than comparison group subjects to be competitively employed, work 40 or more hours in a given month, and have higher earnings, despite controlling for demographic, clinical, work history, disability beneficiary status, and study site confounders. Moreover, the advantage of experimental over comparison group participants increased during the 24-month study period. CONCLUSION: The SE models tailored by integrating clinical and vocational services were more effective than services as usual or unenhanced services.

Estimated payments to employment service providers for persons with mental illness in the Ticket to Work program.

OBJECTIVE: The Ticket to Work and Work Incentives Improvement Act of 1999 removes work disincentives and promotes access to vocational services for people with disabilities. This study calculated the amount of payments that would have been made to employment service providers if study participants had been enrolled in the Ticket program. METHODS: Data were from 450 Social Security Disability Insurance beneficiaries with psychiatric disabilities enrolled in a multisite study of supported employment. Earnings over two years were used to calculate provider payments under two reimbursement formulas used in the Ticket program. RESULTS: Only a quarter of service recipients (26 percent) reached earnings levels that would have triggered provider payments under the first reimbursement formula. Only 4 percent would have completed their trial work period and left the rolls, generating payments under the second formula. CONCLUSIONS: The current provider payment systems of the Ticket to Work program do not reflect the reality of rehabilitation for individuals with severe mental illness. Reforms should take into account outcomes of return-to-work services for this population.

A menu with prices: Annual per person costs of programs addressing community integration.

Information on costs of programs addressing community integration for persons with serious mental illness in the United States, essential for program planning and evaluation, is largely lacking. To address this knowledge gap, community integration programs identified through directories and snowball sampling were sent an online survey addressing program costs and organizational attributes. 64 Responses were received for which annual per person costs (APPC) could be computed. Programs were categorized by type of services provided. Program types differed in median APPCs, though median APPCs identified were consistent with the ranges identified in the limited literature available. Multiple regression was used to identify organizational variables underlying APPCs such as psychosocial rehabilitation program type, provision of EBPs, number of volunteers, and percentage of budget spent on direct care staff, though effects sizes were moderate at best. This study adds tentative prices to the menu of community integration programs, and the implications of these findings for choosing, designing and evaluating programs addressing community integration are discussed.

Measurement of Perceived and Technical Quality of Care for Depression in Racially and Ethnically Diverse Groups.

Measurement of patient satisfaction is now considered essential for providing patient centered care and is an important tool for addressing health care disparities. However, little is known about how ethnically and racially diverse (ERD) groups differ in how they perceive quality, and widely used instruments for measuring perceived quality give little attention to cultural elements of care. This study examined the relationship between the culturally determined beliefs and expectations of four ERD groups (African Americans, Latinos, Portuguese-speakers, and Haitians, total N = 160) and the technical quality of treatment for depression provided in four "culturally-specific" primary care clinics. Using data from the Experiences of Care and Health Outcomes survey, chart reviews and focus groups, the study addressed a set of questions related to the psychometric properties of perceived care measures and the technical quality of care. The groups differed in preferred cultural elements except all preferred inclusion of religion. They did not differ in overall perceived quality. Technical quality was higher for Portuguese and Haitians than for African Americans and Latinos. Implications of group differences for measuring quality are discussed.

Integration of psychiatric and vocational services: a multisite randomized, controlled trial of supported employment.

OBJECTIVE: Although large-scale surveys indicate that patients with severe mental illness want to work, their unemployment rate is three to five times that of the general adult population. This multisite, randomized implementation effectiveness trial examined the impact of highly integrated psychiatric and vocational rehabilitation services on the likelihood of successful work outcomes. METHOD: At seven sites nationwide, 1,273 outpatients with severe mental illness were randomly assigned either to an experimental supported employment program or to a comparison/services-as-usual condition and followed for 24 months. Data collection involved monthly services tracking, semiannual in-person interviews, recording of all paid employment, and program ratings made by using a services-integration measure. The likelihood of competitive employment and working 40 or more hours per month was examined by using mixed-effects random regression analysis. RESULTS: Subjects served by models that integrated psychiatric and vocational service delivery were more than twice as likely to be competitively employed and almost 1(1/2) times as likely to work at least 40 hours per month when the authors controlled for time, demographic, clinical, and work history confounds. In addition, higher cumulative amounts of vocational services were associated with better employment outcomes, whereas higher cumulative amounts of psychiatric services were associated with poorer outcomes. CONCLUSIONS: Supported employment models with high levels of integration of psychiatric and vocational services were more effective than models with low levels of service integration.

Effects of job development and job support on competitive employment of persons with severe mental illness.

OBJECTIVES: Few studies have sought to determine which specific supported employment services improve employment outcomes for people with pyschiatric disabilities. This study examined the effects of job development and job support among other services on acquisition and retention of competitive employment. METHODS: Data used in the analysis came from seven sites of the Employment Intervention Demonstration Program. Employment data were collected weekly for a period up to 24 months for 1,340 participants. A random-effects meta-analysis was conducted. RESULTS: Job development increased the probability of obtaining competitive employment. The effects of job development on job acquisition remained after the effects of other factors were controlled for. Job support was associated with more months in the first competitive job but not total hours worked. However, no evidence for the causal role of job support was found in analyses that tested the effects of job support after the job support was provided. The causal role of job support alone was also cast in doubt by the fact that a substantial overlap existed between individuals who received job support and vocational counseling. CONCLUSIONS: Job development is a very effective service when the goal is job acquisition. Job support is associated with retention of a first competitive job, but its causal role is questionable.

Assessment of Medicaid managed behavioral health care for persons with serious mental illness.

OBJECTIVES: This five-site study compared Medicaid managed behavioral health programs and fee-for-service programs on use and quality of services, satisfaction, and symptoms and functioning of adults with serious mental illness. METHODS: Adults with serious mental illness in managed care programs (N=958) and fee-for-service programs (N=1,011) in five states were interviewed after the implementation of managed care and six months later. After a multiple regression to standardize the groups for case mix differences, a meta-analysis using a random-effects model was conducted, and bioequivalence methods were used to determine whether differences were significant for clinical or policy purposes. RESULTS: A significantly smaller proportion of the managed care group received inpatient care (5.7 percent compared with 11.5 percent). The managed care group received significantly more hours of primary care (4.9 compared with 4.5 hours) and was significantly less healthy. However, none of these differences exceed the bioequivalence criterion of 5 percent. Managed care and fee for service were "not different but not equivalent" on 20 of 34 dependent variables. Cochrane's Q statistic, which measured intersite consistency, was significant for 20 variables. CONCLUSIONS: Managed care and fee-for-service Medicaid programs did not differ on most measures; however, a lack of sufficient power was evident for many measures. Full endorsement of managed care for vulnerable populations will require further research that assumes low penetration rates and intersite variability.

What is evidence?

The evidence-based practice movement rests on the premise that the scientific evidence regarding treatment should be used judiciously to inform treatment decisions. This article focuses on the most fundamental question regarding evidence-based practice: What is evidence? To address this question, the authors first review several of the definitions, criteria, and strategies that have been used to define scientific evidence. Second, a number of critical issues that have been raised regarding the nature of treatment evidence are discussed. Finally, suggestions for further consideration in the process of synthesizing evidence for clinicians are offered.

Does one size fit all? What we can and can't learn from a meta-analysis of housing models for persons with mental illness.

OBJECTIVE: Numerous studies have evaluated the impacts of community housing models on outcomes of persons with severe mental illness. The authors conducted a meta-analysis of 44 unique housing alternatives described in 30 studies, which they categorized as residential care and treatment, residential continuum, permanent supported housing, and nonmodel housing. Outcomes examined included housing stability, symptoms, hospitalization, and satisfaction. METHODS: Outcome scores were converted to effect size measures appropriate to the data. Effect sizes were combined to estimate random effects for housing models, which were then compared. RESULTS: All models achieved significantly greater housing stability than nonmodel housing. This effect was greatest for permanent supported housing (effect size=.63, p<.05). No differences between housing models were significant. For reduction of psychiatric symptoms, only residential care and treatment differed from nonmodel housing (effect size=.65, p<.05). For hospitalization reduction, both residential care and treatment and permanent supported housing differed from nonmodel housing (p<.05). Permanent supported housing achieved the highest effect size (.73) for satisfaction and differed from nonmodel housing and residential care and treatment (p<.001 and p<.05, respectively). CONCLUSIONS: The meta-analysis provides quantitative evidence that compared with nonmodel housing, housing models contribute to stable housing and other favorable outcomes. The findings also support the theory that different housing models achieve different outcomes for different subgroups. Data were not sufficient to fully answer questions designed to enable program planners and providers to better meet consumers' needs. It is important to answer these questions with research that uses common measures and adheres to scientific conventions.

Effects of co-occurring disorders on employment outcomes in a multisite randomized study of supported employment for people with severe mental illness.

Effects of co-occurring disorders on work outcomes were explored among individuals with severe mental illness who were participating in a multisite randomized study of supported employment. At seven sites, 1,273 people were randomly assigned to an experimental supported employment program or a control condition and followed for 2 years. Multivariate regression analysis examined work outcomes including earnings, hours worked, and competitive employment, as well as whether psychiatric disability was disclosed to coworkers and supervisors. Individuals with any comorbidity had lower earnings and were less likely to work competitively. Those with physical comorbidities had lower earnings, worked fewer hours, and were less likely to work competitively. Disclosure was more likely among those with both cognitive and physical comorbidities, as well as those with learning disabilities. Competitive employment was less likely among those with intellectual disability, visual impairment, and human immunodeficiency virus/acquired immuno-deficiency syndrome. The experimental condition was positively related to all outcomes except disclosure. The results suggest that, with some exceptions, comorbidities affect employment outcomes, requiring tailored services and supports to promote vocational success.

Desired attributes of evidence assessments for evidence-based practices.

In this paper we describe three approaches to assessing evidence for stakeholders interested in evidence-based practices: narrative reviews, systematic reviews (including meta-analyses), and registries. We then compare the approaches in terms of the degree to which they posses desired attributes of evidence assessments. Our review suggests that hybrid approaches that combined the best features of all three should be pursued to further the use of evidence-based practices, and that such hybrids are possible given the capacity of the World Wide Web. We conclude by stressing the need for empirical research on evidence assessments.

Demographic characteristics and employment among people with severe mental illness in a multisite study.

People with psychiatric disabilities experience disproportionately high rates of unemployment. As research evidence is mounting regarding effective vocational programs, interest is growing in identifying subgroup variations. Data from a multisite research and demonstration program were analyzed to identify demographic characteristics associated with employment outcomes, after adjusting for the effects of program, services, and study site. Longitudinal analyses found that people with more recent work history, younger age, and higher education were more likely to achieve competitive employment and to work more hours per month, while race and gender effects varied by employment outcome. Results provide strong evidence of demographic subgroup variation and need.

Clinical factors associated with employment among people with severe mental illness: findings from the employment intervention demonstration program.

Research has shown that supported employment programs are effective in helping psychiatric outpatients achieve vocational outcomes, yet not all program participants are able to realize their employment goals. This study used 24 months of longitudinal data from a multisite study of supported employment interventions to examine the relationship of patient clinical factors to employment outcomes. Multivariate random regression analysis indicated that, even when controlling for an extensive series of demographic, study condition (experimental versus control), and work history covariates, clinical factors were associated with individuals' ability to achieve competitive jobs and to work 40 or more hours per month. Poor self-rated functioning, negative psychiatric symptoms, and recent hospitalizations were most consistently associated with failure to achieve these employment outcomes. These findings suggest ways that providers can tailor supported employment programs to achieve success with a diverse array of clinical subpopulations.