Racial and Ethnic Disparities in Treatment and Treatment Type for Depression in a National Sample of Medicaid Recipients.

OBJECTIVE: The purpose of this secondary data analysis was to describe racial-ethnic disparities in receipt of depression treatment and treatment modality among adult Medicaid beneficiaries with depression from a nationally representative sample-28 states and the District of Columbia-of Medicaid beneficiaries (N=599,421). METHODS: Medicaid claims data were extracted from the full 2008-2009 Medicaid Analytic Extract file. The primary outcome was type of depression treatment: medication only, therapy only, medication and therapy, and no treatment. The secondary outcome was treatment for depression (yes-no). Crude and adjusted odds ratios (AORs) were generated for univariate and multivariate models, respectively, and 95% confidence intervals of odds ratios and p values were calculated. RESULTS: There were 599,421 individuals in the sample. Rates of depression treatment were lower for African Americans and Hispanics, compared with Caucasians. Percentages receiving no treatment were 19.9% of African Americans, 15.2% of Hispanics, and 11.9% of Caucasians. After full adjustment, African Americans were about half as likely as Caucasians to receive treatment (AOR=0.52), Hispanics were about a third as likely (AOR=0.71), and those from other racial-ethnic groups were about a fifth as likely (AOR=0.84). Caucasians were more likely than any other group to receive medication only. CONCLUSIONS: This study contributes to evidence about the intersection of social factors and health outcomes and discusses health care engagement, stigma, and policy drivers of racial-ethnic disparities. The study is the first to identify disparities in rates and types of depression treatment among racial-ethnic subgroups of Medicaid beneficiaries in a nationally representative sample.

Improving Behavioral Health Equity through Cultural Competence Training of Health Care Providers.

Racial/ethnic disparities have long persisted in the United States despite concerted health system efforts to improve access and quality of care among African Americans and Latinos. Cultural competence in the health care setting has been recognized as an important feature of high-quality health care delivery for decades and will continue to be paramount as the society in which we live becomes increasingly culturally diverse. Unfortunately, there is limited empirical evidence of patient health benefits of a culturally competent health care workforce in integrated care, its feasibility of implementation, and sustainability strategies. This article reviews the status of cultural competence education in health care, the merits of continued commitment to training health care providers in integrated care settings, and policy and practice strategies to ensure emerging health care professionals and those already in the field are prepared to meet the health care needs of racially and ethnically diverse populations.

Collaborative Action on Child Equity: Lessons from the Field.

The Collaborative Action on Child Equity (CACE) pursued child-focused program and policy research through the Morehouse School of Medicine's Transdisciplinary Collaborative Center (TCC). CACE engaged with partners representing 13 states in the United States to implement the Smart and Secure Children Parent Leadership Program (SSC) and to develop local child-focused Policy Action Plans. The objectives of SSC are to support the development of parental agency and leadership in order to achieve positive health and academic readiness among school-aged children. Of the 13 partners, 9 were able to successfully implement SSC, with more than 350 parent-peer learners completing the program. Additionally, several partners were able to successfully develop Policy Action Plans. We discuss our efforts to bring SSC to scale in a national replication effort and to build policy development, implementation and evaluation capacity in organizations serving children and families. We highlight lessons learned in this replication effort and consider their implications for revisions to our training protocols, recruitment and implementation strategies, methods for providing technical assistance and evaluation models. SSC has demonstrated encouraging efficacy results, was developed using community-based participatory research methods and, as such, the lessons learned are critical for how we engage diverse communities to advance positive child development and academic success.

Accountable Care Organizations' Performance in Depression: Lessons for Value-Based Payment and Behavioral Health.

Value-based payment initiatives, such as the Medicare Shared Savings Program (MSSP), offer the possibility of using financial incentives to drive improvements in mental health and substance use outcomes. In the past 2 years, Accountable Care Organizations (ACOs) participating in the MSSP began to publicly report on one behavioral health outcome-Depression Remission at Twelve Months, which may indicate how value-based payment incentives have impacted mental health and substance use, and if reforms are needed. For ACOs that meaningfully reported performance on the depression remission measure in 2017, the median rate of depression remission at 12 months was 8.33%. A recent meta-analysis found that the average rate of spontaneous depression remission at 12 months absent treatment was approximately 53%. Although a number of factors likely explain these results, the current ACO design does not appear to incentivize improved behavioral health outcomes. Four changes in value-based payment incentive design may help to drive better outcomes: (1) making data collection easier, (2) increasing the salience of incentives, (3) building capacity to implement new interventions, and (4) creating safeguards for inappropriate treatment or reporting.

The Fierce Urgency of Now: Improving Outcomes for Justice-Involved People With Serious Mental Illness and Substance Misuse.

People with serious mental illness are more likely to be arrested multiple times for the same crime, spend more time in jail before adjudication, serve longer sentences, and have higher recidivism rates than those without mental illness. Several conceptual foundations, such as the sequential intercept model and the risk-needs-responsivity model, have been developed to help communities address the overrepresentation of people with mental illness in the criminal justice system. The Stepping Up Initiative is a national effort to enlist counties to commit to reduce the number of people with mental illness in their jails. The 21st Century Cures Act has created opportunities to fund community treatment and help people with serious mental illness live a productive life in their community. Public officials may need to be shown the substantial cost savings likely to accrue from an investment in effective community treatment. The time to act is now.

A Tipping Point for Measurement-Based Care.

(Reprinted with permission from Psychiatric Services, 2017; 68:179-188).

Patient and Practitioner Perspectives on Culturally Centered Integrated Care to Address Health Disparities in Primary Care.

INTRODUCTION: Addressing the multifaceted health and mental health needs of ethnically and culturally diverse individuals is a challenge within the current health care system. Integrated care provides a promising approach to improve mental health treatment-seeking disparities; however, adaptation of care models to impact African Americans is lacking. Although resources to support engagement of diverse populations in depression care exist, little has been developed to tailor patient preferences in accessing and engaging mental health services that are integrated into primary care. OBJECTIVE: Our research seeks to add a cultural focus to the existing literature concerning integrated health care models to help address depression and selected co-occurring chronic health conditions in primary care settings. METHODS: Thirty-two adult patients of an integrated primary care clinic participated in focus groups discussing their individual health experiences. Nine health care practitioners/administrators from five different integrated practice settings in the Atlanta, GA, area participated in key informant interviews. MAIN OUTCOME MEASURES: Transcripts were analyzed for key themes related to depression care, perceived unmet cultural needs, and desired adaptations. RESULTS: Common themes emerged such as the importance of peer-support and community engagement as areas of patient interest. Participants had good knowledge in recognizing depressive symptoms but were less knowledgeable about treatment options and expectations of treatment. The administrative and practitioner perspective suggests that patient preferences are valued and perceived as valid. CONCLUSION: It is critical that strategies and models are developed to improve health care among underserved minorities because current models offer variable efficacy among this population.

Racial disparities in the impact of chronic pruritus: A cross-sectional study on quality of life and resource utilization in United States veterans.

BACKGROUND: Chronic pruritus has a lifetime prevalence of up to 26% in the worldwide population. Research has shown that the incidence and quality of life (QoL) impact of chronic pruritus varies by race. OBJECTIVE: We sought to explore the effects of race on specific pruritus-related QoL factors and resource utilization. METHODS: We performed a cross-sectional, national telephone survey of 6000 US veterans randomly sampled from the Veterans Hospital Patient Database. We administered surveys to assess QoL impact and resource utilization of chronic pruritus. RESULTS: Nonwhites overall reported higher levels of burning and scarring with their pruritus. African Americans had a significantly greater emotional impact and use of special soaps, lotions, and clothes. African Americans were also more likely to visit their primary care provider for pruritus (P = .03), yet had similar numbers of specialty care visits. LIMITATIONS: Because our sample was drawn from a veteran population, generalizability may be limited. CONCLUSION: The data indicate a racial disparity in specific QoL impact and resource utilization from pruritus. These findings merit further exploration into explanations, such as access, communication, trust of the medical system, and biologic differences.

The Readiness for Integrated Care Questionnaire (RICQ): An instrument to assess readiness to integrate behavioral health and primary care.

Integration of behavioral health and primary care services is a promising approach for reducing health disparities. The growing national emphasis on care coordination has mobilized efforts to integrate behavioral health and primary care services across the United States. These efforts align with broader health care system goals of improving health care quality, health equity, utilization efficiency, and patient outcomes. Drawing from our work on a multiyear integrated care initiative (Integrated Care Leadership Program; ICLP) and an implementation science heuristic for organizational readiness (Readiness = Motivation x General Capacity and Innovation-Specific Capacity; R = MC2), this article describes the development and implementation of a tool to assess organizational readiness for integrated care, referred to as the Readiness for Integrated Care Questionnaire (RICQ). The tool was piloted with 11 health care practices that serve vulnerable, underprivileged populations. Initial results from the RICQ revealed that participating practices were generally high in motivation, innovation-specific capacities, and general capacities at the start of ICLP. Additionally, analyses indicated that practices particularly needed support with increasing staff capacities (general knowledge and skills), improving access to and use of resources, and simplifying the steps in integrating care so the effort appears less daunting and difficult to health care team members. We discuss insights from the initial use of RICQ and practical implications of the new tool for driving integrated care efforts that can contribute to health equity. (PsycINFO Database Record

Assessing Telemedicine Utilization by Using Medicaid Claims Data.

OBJECTIVE: This study characterized telemedicine utilization among Medicaid enrollees by patients' demographic characteristics, geographic location, enrollment type, eligibility category, and clinical conditions. METHODS: This study used 2008-2009 Medicaid claims data from 28 states and the District of Columbia to characterize telemedicine claims (indicated by GT for professional fee claims or Q3014 for facility fees) on the basis of patients' demographic characteristics, geographic location, enrollment type, eligibility category, and clinical condition as indicated by ICD-9 codes. States lacking Medicaid telemedicine reimbursement policies were excluded. Chi-square tests were used to compare telemedicine utilization rates and one-way analysis of variance was used to estimate mean differences in number of telemedicine encounters among subgroups. RESULTS: A total of 45,233,602 Medicaid enrollees from the 22 states with telemedicine reimbursement policies were included in the study, and .1% were telemedicine users. Individuals ages 45 to 64 (16.4%), whites (11.3%), males (8.5%), rural residents (26.0%), those with managed care plans (7.9%), and those categorized as aged, blind, and disabled (28.1%) were more likely to receive telemedicine (p<.001). Nearly 95% of telemedicine claims were associated with a behavioral health diagnosis, of which over 50% were for bipolar disorder and attention-deficit disorder or attention-deficit hyperactivity disorder (29.3% and 23.4%, respectively). State-level variation was high, ranging from .0 to 59.91 claims per 10,000 enrollees (Arkansas and Arizona, respectively). CONCLUSIONS: Despite the touted potential for telemedicine to improve health care access, actual utilization of telemedicine in Medicaid programs was low. It was predominantly used to treat behavioral health diagnoses. Reimbursement alone is insufficient to support broad utilization for Medicaid enrollees.

A Tipping Point for Measurement-Based Care.

OBJECTIVE: Measurement-based care involves the systematic administration of symptom rating scales and use of the results to drive clinical decision making at the level of the individual patient. This literature review examined the theoretical and empirical support for measurement-based care. METHODS: Articles were identified through search strategies in PubMed and Google Scholar. Additional citations in the references of retrieved articles were identified, and experts assembled for a focus group conducted by the Kennedy Forum were consulted. RESULTS: Fifty-one relevant articles were reviewed. There are numerous brief structured symptom rating scales that have strong psychometric properties. Virtually all randomized controlled trials with frequent and timely feedback of patient-reported symptoms to the provider during the medication management and psychotherapy encounters significantly improved outcomes. Ineffective approaches included one-time screening, assessing symptoms infrequently, and feeding back outcomes to providers outside the context of the clinical encounter. In addition to the empirical evidence about efficacy, there is mounting evidence from large-scale pragmatic trials and clinical demonstration projects that measurement-based care is feasible to implement on a large scale and is highly acceptable to patients and providers. CONCLUSIONS: In addition to the primary gains of measurement-based care for individual patients, there are also potential secondary and tertiary gains to be made when individual patient data are aggregated. Specifically, aggregated symptom rating scale data can be used for professional development at the provider level and for quality improvement at the clinic level and to inform payers about the value of mental health services delivered at the health care system level.

Community Engaged Leadership to Advance Health Equity and Build Healthier Communities.

Health is a human right. Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential. Addressing the multi-faceted health needs of ethnically and culturally diverse individuals in the United States is a complex issue that requires inventive strategies to reduce risk factors and buttress protective factors to promote greater well-being among individuals, families, and communities. With growing diversity concerning various ethnicities and nationalities; and with significant changes in the constellation of multiple of risk factors that can influence health outcomes, it is imperative that we delineate strategic efforts that encourage better access to primary care, focused community-based programs, multi-disciplinary clinical and translational research methodologies, and health policy advocacy initiatives that may improve individuals' longevity and quality of life.

Context matters: A community-based study of urban minority parents' views on child health.

BACKGROUND: Among children, there are substantial ethno-racial minority disparities across a broad range of health-related behaviors, experiences, and outcomes. Addressing these disparities is important, as childhood and adolescence establish health trajectories that extend throughout life. METHODS: The current study employed a community-based participatory research approach to gain community insight on child health priorities and to frame an intervention aimed at improving the health of minority children. Eight focus groups were conducted among seventy-five African American parents in a Southeastern city. The current study was guided by an ecological theoretical framework. RESULTS: Although the focus of this investigation was on community identification of child health priorities, participants cited, as root determinants, contextual factors, which included lack of healthy food options, lack of spaces for physical activity, and community violence. These co-occurring factors were related to limited engagement in outdoor activities and physical activity, increased obesity, and poor mental health and coping. Poor parenting was cited as the most substantial barrier to improving child health outcomes, and quality parenting was identified as the most important issue to address for community programs focused on promoting the health and success of children. For improving health outcomes for children in their neighborhoods, establishment of positive social capital and constructive activities were also cited. CONCLUSIONS: These results reinforce social determinants of health as influences on child health outcomes and describe how community engagement can address potential solutions through interventions that resonate with program participants.

Improving Quality of Emergency Care Through Integration of Mental Health.

The goal of this study was to better integrate emergency medical and psychiatric care at a large urban public hospital, identify impact on quality improvement metrics, and reduce healthcare cost. A psychiatric fast track service was implemented as a quality improvement initiative. Data on disposition from the emergency department from January 2011 to May 2012 for patients impacted by the pilot were analyzed. 4329 patients from January 2011 to August 2011 (pre-intervention) were compared with 4867 patients from September 2011 to May 2012 (intervention). There was a trend of decline on overall quality metrics of time to triage and time from disposition to discharge. The trend analysis of the psychiatric length of stay and use of restraints showed significant reductions. Integrated emergency care models are evidence-based approach to ensuring that patients with mental health needs receive proper and efficient treatment. Results suggest that this may also improve overall emergency department's throughput.

Using a self-service kiosk to identify behavioural health needs in a primary care clinic serving an urban, underserved population.

BACKGROUND: Integration of behavioural health into primary care clinics is an established model of care and important approach to eliminating mental health disparities, but demands on provider time is a barrier to mental health screening. The purpose of this study was to determine the feasibility of using a kiosk placed in a primary care clinic to screen for multiple mental health disorders. METHODS: Quality improvement initiative with Plan-Do-Study-Act implementation and time series monitoring of utilisation outcomes. RESULTS: A total of 281 screens were completed identifying positive screens for depression (30%) and bipolar disorder (17%). Post-traumatic stress disorder and concerning substance use were less common. CONCLUSIONS: Development of health information technology to facilitate behavioural health assessment in primary care is a promising approach to integrated care and provides additional benefits of population health monitoring.

Goal-Directed Resilience in Training (GRIT): A Biopsychosocial Model of Self-Regulation, Executive Functions, and Personal Growth (Eudaimonia) in Evocative Contexts of PTSD, Obesity, and Chronic Pain.

This paper presents a biopsychosocial model of self-regulation, executive functions, and personal growth that we have applied to Goal-Directed Resilience in Training (GRIT) interventions for posttraumatic stress disorder (PTSD), obesity, and chronic pain. Implications of the training for the prevention of maladaptation, including psychological distress and health declines, and for promoting healthy development are addressed. Existing models of attention, cognition, and physiology were sourced in combination with qualitative study findings in developing this resilience skills intervention. We used qualitative methods to uncover life skills that are most salient in cases of extreme adversity, finding that goal-directed actions that reflected an individual's values and common humanity with others created a context-independent domain that could compensate for the effects of adversity. The efficacy of the resilience skills intervention for promoting positive emotion, enhancing neurocognitive capacities, and reducing symptoms was investigated in a randomized controlled trial with a veteran population diagnosed with PTSD. The intervention had low attrition (8%) and demonstrated improvement on symptom and wellbeing outcomes, indicating that the intervention may be efficacious for PTSD and that it taps into those mechanisms which the intervention was designed to address. Feasibility studies for groups with comorbid diagnoses, such as chronic pain and PTSD, also showed positive results, leading to the application of the GRIT intervention to other evocative contexts such as obesity and chronic pain.

Improving Service Coordination and Reducing Mental Health Disparities Through Adoption of Electronic Health Records.

Despite widespread support for removing barriers to the use of electronic health records (EHRs) in behavioral health care, adoption of EHRs in behavioral health settings lags behind adoption in other areas of health care. The authors discuss barriers to use of EHRs among behavioral health care practitioners, suggest solutions to overcome these barriers, and describe the potential benefits of EHRs to reduce behavioral health care disparities. Thoughtful and comprehensive strategies will be needed to design EHR systems that address concerns about policy, practice, costs, and stigma and that protect patients' privacy and confidentiality. However, these goals must not detract from continuing to challenge the notion that behavioral health and general medical health should be treated as separate and distinct. Ultimately, utilization of EHRs among behavioral health care providers will improve the coordination of services and overall patient care, which is essential to reducing mental health disparities.

The effect of resilience on posttraumatic stress disorder in trauma-exposed inner-city primary care patients.

Posttraumatic stress disorder (PTSD) has previously been associated with increased risk for a variety of chronic medical conditions and it is often underdiagnosed in minority civilian populations. The current study examined the effects of resilience on the likelihood of having a diagnosis of PTSD in an inner-city sample of primary care patients (n=767). We measured resilience with the Connor-Davidson Resilience Scale, trauma with the Childhood Trauma Questionnaire and Trauma Events Inventory, and assessed for PTSD with the modified PTSD symptom scale. Multiple logistic regression model with presence/absence of PTSD as the outcome yielded 3 significant factors: childhood abuse, nonchild abuse trauma, and resilience. One type of childhood abuse in moderate to severe range (OR, 2.01; p = .0001), 2 or more types of childhood abuse in moderate to severe range (OR, 4.00; p < or = .0001), and 2 or more types of nonchildhood abuse trauma exposure (OR, 3.33; p < or = .0001), were significantly associated with an increased likelihood of PTSD, while resilience was robustly and significantly associated with a decreased likelihood of PTSD (OR, 0.93; p < or = .0001). By understanding the role of resilience in recovery from adverse experiences, improved treatment and interventional methods may be developed. Furthermore, these results suggest a role for assessing resilience in highly traumatized primary care populations as a way to better characterize risk for PTSD and direct screening/psychiatric referral efforts.