Integrating Primary Care Into Community Mental Health Centers: Impact on Utilization and Costs of Health Care.

OBJECTIVE: This evaluation was designed to assess the impact of providing integrated primary and mental health care on utilization and costs for outpatient medical, inpatient hospital, and emergency department treatment among persons with serious mental illness. METHODS: Two safety-net, community mental health centers that received a Substance Abuse and Mental Health Services Administration Primary and Behavioral Health Care Integration (PBHCI) grant were the focus of this study. Clinic 1 had a ten-year history of providing integrated services whereas clinic 2 began integrated services with the PBHCI grant. Difference-in-differences (DID) analyses were used to compare individuals enrolled in the PBHCI programs (N=373, clinic 1; N=389, clinic 2) with propensity score-matched comparison groups of equal size at each site by using data obtained from medical records. RESULTS: Relative to the comparison groups, a higher proportion of PBHCI clients used outpatient medical services at both sites following program enrollment (p<.003, clinic 1; p<.001, clinic 2). At clinic 1, PBHCI was also associated with a reduction in the proportion of clients with an inpatient hospital admission (p=.04) and a trend for a reduction in inpatient hospital costs per member per month of $217.68 (p=.06). Hospital-related cost savings were not observed for PBHCI clients at clinic 2 nor were there significant differences between emergency department use or costs for PBHCI and comparison groups at either clinic. CONCLUSIONS: Investments in PBHCI can improve access to outpatient medical care for persons with severe mental illness and may also curb hospitalizations and associated costs in more established programs.

Barriers and Facilitators to Coordinating Care With High-Risk, High-Cost Disabled Medicaid Beneficiaries: Perspectives of Frontline Staff and Participating Clients.

This evaluation was designed to examine the perspectives of 15 frontline staff who implemented a managed care program and 154 high-risk, high-cost disabled Medicaid clients who were participants in the program. Results indicated that positive relationships between staff and clients played a key role in facilitating program implementation. Challenges included finding ways to provide a wide breadth of services including food, shelter, and transportation; handling difficulties following from staff turnover; and creating transitions of care for clients to community health clinics. Staff identified training in motivational interviewing and having both nurse care managers and social workers collaboratively deliver the intervention as among the most powerful components of the program. Staff and clients expressed high levels of satisfaction with the program, and clients believed they were experiencing positive impacts of the program. Lessons learned from this study may inform the design of services as the Affordable Care Act continues to unfold.

A randomized controlled trial of intensive care management for disabled Medicaid beneficiaries with high health care costs.

OBJECTIVE: To evaluate outcomes of a registered nurse-led care management intervention for disabled Medicaid beneficiaries with high health care costs. DATA SOURCES/STUDY SETTING: Washington State Department of Social and Health Services Client Outcomes Database, 2008-2011. STUDY DESIGN: In a randomized controlled trial with intent-to-treat analysis, outcomes were compared for the intervention (n = 557) and control groups (n = 563). A quasi-experimental subanalysis compared outcomes for program participants (n = 251) and propensity score-matched controls (n = 251). DATA COLLECTION/EXTRACTION METHODS: Administrative data were linked to describe costs and use of health services, criminal activity, homelessness, and death. PRINCIPAL FINDINGS: In the intent-to-treat analysis, the intervention group had higher odds of outpatient mental health service use and higher prescription drug costs than controls in the postperiod. In the subanalysis, participants had fewer unplanned hospital admissions and lower associated costs; higher prescription drug costs; higher odds of long-term care service use; higher drug/alcohol treatment costs; and lower odds of homelessness. CONCLUSIONS: We found no health care cost savings for disabled Medicaid beneficiaries randomized to intensive care management. Among participants, care management may have the potential to increase access to needed care, slow growth in the number and therefore cost of unplanned hospitalizations, and prevent homelessness. These findings apply to start-up care management programs targeted at high-cost, high-risk Medicaid populations.

Testing the effects of brief intervention in primary care for problem drug use in a randomized controlled trial: rationale, design, and methods.

BACKGROUND: A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy. METHODS/DESIGN: The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases. DISCUSSION: This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT00877331.

Changes in the health burden of a national sample of children with asthma.

This paper focused on the extent to which factors that are modifiable by health policies or provider recommendations influenced the level and changes in the burden of childhood asthma. Demographic factors, access to health care services, and asthma control activities were posited to potentially influence the level and changes in health burden of children with asthma. The Medical Expenditure Panel Survey data from 1996-1999 on 3-11 year old U.S. children with asthma (N=784) were used. The findings of multilevel models of perceived burden indicated unfavorable trajectories among those families who had public health insurance. Asthma control activities were associated with favorable trajectories of both perceived and objectively measured burden. These findings emphasized the significance of asthma control and access to high quality and stable health care services as health policy targets.

Low socioeconomic status and mental health care use among respondents with anxiety and depression in the NCS-R.

OBJECTIVE: This study sought to determine whether previously reported poor outcomes among patients of low socioeconomic status who have depression and anxiety could result from not receiving mental health treatment or from receiving minimally adequate treatment. METHODS: The study sample consisted of 1,772 participants in the National Comorbidity Survey Replication (NCS-R) who met criteria for a mood or anxiety disorder. Bivariate and multivariate logistic regression analyses were used to examine associations between education, income, and assets and receipt of treatment and quality of treatment (minimally adequate treatment) for mood and anxiety disorders in sectors with the capacity to deliver evidence-based treatments (the general medical and mental health specialty sectors). Multivariate analyses controlled for age, gender, race-ethnicity, marital status, health insurance, and urbanicity. RESULTS: Age, gender, marital status, and race-ethnicity were strong and fairly consistent predictors of mental health services use, with some modest variations by sector. In contrast, in bivariate and multivariate analyses, education, income, and assets were minimally related to use of mental health care and to receipt of minimally adequate care in both general medical and mental health specialty sectors. CONCLUSIONS: Socioeconomic status does not appear to play a major role in determining aspects of treatment for depression and anxiety disorders. Poor outcomes of depressed and anxious patients with low socioeconomic status may be due to differences in quality of care beyond the minimally adequate level assessed in this study or to factors unrelated to quality of care that could counteract effective treatments, such as the presence of ongoing chronic stress.

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.

Health care utilization by children with asthma.

INTRODUCTION: We examined how differences in health service utilization among children with asthma are associated with race/ethnicity, socioeconomic status (family income, mother's education), and health insurance coverage. METHODS: We analyzed Medical Expenditure Panel Survey data from 1996 through 2000 (982 children younger than 18 years with asthma). We calculated percentages and mean distributions, odds ratios, and incidence rate ratios. RESULTS: Non-Hispanic black children used more urgent care services and fewer preventive health services. Children in low-income families (125%-199% of the poverty line) had the lowest levels of prescription fills and general checkups. Children whose mothers had more education had more checkups and fewer emergency department visits. Children who were insured during the 2-year study period used more health services for asthma, not including emergency department visits. CONCLUSION: Minority children and children of socioeconomically disadvantaged families use more urgent care and less preventive care for asthma. Children without health insurance use fewer health services overall. Future research should address how related factors might explain health services utilization in effectively managing asthma in children.

Does your child have asthma? Filled prescriptions and household report of child asthma.

INTRODUCTION: Surveys are central for information on asthma prevalence. Recently, the validity of parental reports of pediatric asthma has been questioned. Confidence is examined in the report of asthma for children, obtained in a survey from the adult household member most knowledgeable about household health care (MKA). METHOD: MKA reports of asthma are compared with pharmacy records of prescriptions beneficial in asthma treatment ("asthma medications") for children 0 to 17 years old in the 1996 Medical Expenditure Panel Survey. RESULTS: "Asthma medications" were filled for 6.5% of children, yet the MKA did not report asthma for 47.3% of them. However, for 61.2% of these children, the MKA reported plausible alternative medical conditions. For 9.0%, diagnosis information was missing. Among children with an "asthma medication," the MKA was less likely to report either asthma or a plausible alternative diagnosis for girls and for children 0 to 5 years of age. Reporting was not statistically different by child race/ethnicity, household income, education level, and MKA English language proficiency. DISCUSSION: Surveys do not overlook as many children with asthma as previously reported. Among children with "asthma medications," only sex and age appear to be different for children whose MKA reported either asthma or a plausible alternative diagnosis versus those whose MKA did not report either.

Family perceptions of the usual source of care among children with asthma by race/ethnicity, language, and family income.

A usual source of care (USC) can serve as the foundation for good primary health care and is critical for children living with a chronic health condition. This study applies national data to the following objectives: (1) describe family reports of the presence and characteristics of the USC for children with asthma; (2) examine evidence of systematic differences in the USC for these children with asthma by race/ethnicity, English language proficiency in Hispanic respondents, and family income; and (3) conduct multivariate analysis adjusting for possible confounding factors to examine independent effects of race/ethnicity, language, and income. Data from the 1996-2000 Medical Expenditure Panel Survey (MEPS) were analyzed. Overall, 95% of children with asthma had a USC, with Spanish-speaking Hispanics least likely to report a USC (89%). There were significant differences in USC attributes by race/ethnicity, language, and income, with the largest differences by type of provider and accessibility. Hispanics with poor English language proficiency had the greatest accessibility barriers.

Presence and characteristics of medical home and health services utilization among children with asthma.

INTRODUCTION: Having a medical home is advocated by the National Association of Pediatric Nurse Practitioners and others, yet there is limited research that documents desired health benefits. We examine the presence of medical home characteristics and describe relationships between medical home and health services utilization in a national sample that includes children with asthma. METHOD: Medical home is represented by: (a) the presence of a usual source of care (USC), (b) identification of a named person as USC, and (c) a 10-item index of other medical home characteristics. Health services utilization over a calendar year is measured by (a) emergency department visits for asthma, (b) wellness examination, and (c) rescue bronchodilator fill/refill. Analyses include chi-square and logistic regression. RESULTS: A USC was reported for 95% of participants. Children with a USC were more likely to have a wellness examination (odds ratio, 2.10; 95% confidence interval, 1.15-3.81). Overall, 51% reported the USC to be a facility versus a named person. Identifying a person as the USC was related to higher scores on the 10-item medical home index but not to other outcomes. DISCUSSION: Most parents were satisfied with the USC. Benefits of having a USC, but not necessarily a named person, appear in preventive actions.