Increased Attendance During Rapid Implementation of Telehealth for Substance Use Disorders During COVID-19 at the Largest Public Hospital System in the United States.

OBJECTIVE: The objective of this study is to examine differences between; telehealth and in-person visits during COVID-19 and in a pre-COVID-19 reference period; COVID-19 televisit completion for patients with varying engagement in treatment during the reference period. METHODS: Electronic medical record data were collected and analyzed with chi-squared or t-tests to compare patient demographics. Generalized estimating equations for estimating the odds of outcomes were used, controlling for demographics. RESULTS: Patients were 3.34 and 1.74 times more likely to complete a telehealth visit (n = 11,839) compared with an in-person visit during (n = 7,917) and prior (n = 15,497) to COVID-19. For patients on buprenorphine, patients with no prior in-person visits during the pre-televisit period were 2.26 more likely to complete televisits compared with patients with two or more prior in-person visits. For all patients, those with two or more prior in-person visits in the reference period were 1.27 times more likely to complete a televisit compared with a patient with no in-person visits during the pre-televisit period. There was no significant difference when comparing with patients who had only one prior in-person visit to those patients with no prior visits. CONCLUSIONS: In this study, outpatient substance use disorder (SUD) telehealth appointments were associated with higher odds of visit completion compared with in-person visits during and prior to COVID-19. Patients receiving buprenorphine, without prior in person visits, were more likely to attend if they did not have in-person visits prior to COVID-19. Regulators should consider permanently adopting telehealth flexibilities for SUD treatment once the federal emergency status has ended.

Integrating substance use peer support and screening brief intervention and referral to treatment services in the emergency department: a descriptive study of the ED leads program.

BACKGROUND: The ED Leads program was introduced to 11 emergency departments (EDs) within New York City public hospitals from 2018 to 2019 to address a need for addiction support services in the ED. The purpose of this study is to (i) describe the ED Leads blended licensed-clinician and peer counselor team model in the ED at three hospitals, (ii) provide a descriptive analysis of patient engagement and referrals to substance use disorder (SUD) care post-intervention, and (iii) highlight potential barriers and facilitators to implementing the model. METHODS: The program intended to combine Screening Brief Intervention and Referral to Treatment and peer support services. The authors analyzed electronic medical records data for patients encountered by ED Leads in the first 120 days of program launch. Data included the outcome of an encounter when a patient was engaged with one or both staff types, and 7-day attendance at an SUD treatment appointment when a patient accepted a referral within the 11-hospital system. RESULTS: There were 1785 patients approached by ED Leads staff during the study period. Engagement differed by staff type and patient demographics, and encounter outcomes varied significantly by hospital. Eighty-four percent (N = 1503) of patients who were approached engaged with at least one staff type, and 6% (N = 86) engaged with both. Patients were predominantly male (N = 1438, 81%) with an average age of 45 (SD = 13), and enrolled in Medicaid (N = 1062, 59%). A majority (N = 801, 45%) had alcohol use disorder. Of the patients who accepted a referral within the system (N = 433), 63% received treatment services within 7 days of the ED Leads encounter, a majority at detoxification treatment (N = 252, 58%). CONCLUSIONS: This study describes the potential value and challenges of implementing a blended peer counselor and licensed clinician model in the ED to provide SUD services. While teams provided a high volume of referrals and the analysis of post-intervention treatment follow up is promising, the blended team model was not fully realized, making it difficult to assess the benefits of this combined service. Further research might examine patient outcomes among ED patients who are offered services by both a peer counselor and licensed clinician.

Telephonic Outreach to Engage Patients with Substance Use Disorder Post-Hospitalization During the COVID-19 Pandemic.

During the initial COVID-19 surge, one public hospital in NYC updated their post-discharge outreach approach for patients with substance use disorder, as part of the CATCH (Consult for Addiction Treatment and Care in Hospitals) program. Beginning April 1, 2020, three peers and two addiction counselors attempted telephonic outreach to patients who received a CATCH consultation during hospitalization from program launch (October 7, 2019) through March 31, 2020 (n = 329). Outreach calls could include counseling, in-depth peer support, and referrals to substance use services (SUS)-a significant expansion of the services offered via outreach pre-pandemic. CATCH staff successfully reached 29.5% of patients and provided 77.6% of them with supportive counseling and referrals. Thirty percent of unsuccessful calls were due to inactive numbers, and only 8% of patients without housing were reached. Telephonic outreach established a low-barrier connection between patients and SUS that may be valuable during any period, including non-COVID times. Future interventions that address social determinants such as housing and cell phone access concomitantly with substance use should be considered by addiction consultation services to potentially reduce acute care utilization and improve health outcomes.

Demographic Determinants and Geographical Variability of COVID-19 Vaccine Hesitancy in Underserved Communities: Cross-sectional Study.

BACKGROUND: COVID-19 hospitalizations and deaths disproportionately affect underserved and minority populations, emphasizing that vaccine hesitancy can be an especially important public health risk factor in these populations. OBJECTIVE: This study aims to characterize COVID-19 vaccine hesitancy in underserved diverse populations. METHODS: The Minority and Rural Coronavirus Insights Study (MRCIS) recruited a convenience sample of adults (age≥18, N=3735) from federally qualified health centers (FQHCs) in California, the Midwest (Illinois/Ohio), Florida, and Louisiana and collected baseline data in November 2020-April 2021. Vaccine hesitancy status was defined as a response of "no" or "undecided" to the question "Would you get a coronavirus vaccine if it was available?" ("yes" categorized as not hesitant). Cross-sectional descriptive analyses and logistic regression models examined vaccine hesitancy prevalence by age, gender, race/ethnicity, and geography. The expected vaccine hesitancy estimates for the general population were calculated for the study counties using published county-level data. Crude associations with demographic characteristics within each region were assessed using the chi-square test. The main effect model included age, gender, race/ethnicity, and geographical region to estimate adjusted odds ratios (ORs) and 95% CIs. Interactions between geography and each demographic characteristic were evaluated in separate models. RESULTS: The strongest vaccine hesitancy variability was by geographic region: California, 27.8% (range 25.0%-30.6%); the Midwest, 31.4% (range 27.3%-35.4%); Louisiana, 59.1% (range 56.1%-62.1%); and Florida, 67.3% (range 64.3%-70.2%). The expected estimates for the general population were lower: 9.7% (California), 15.3% (Midwest), 18.2% (Florida), and 27.0% (Louisiana). The demographic patterns also varied by geography. An inverted U-shaped age pattern was found, with the highest prevalence among ages 25-34 years in Florida (n=88, 80.0%,) and Louisiana (n=54, 79.4%; P<.05). Females were more hesitant than males in the Midwest (n= 110, 36.4% vs n= 48, 23.5%), Florida (n=458, 71.6% vs n=195, 59.3%), and Louisiana (n= 425, 66.5% vs. n=172, 46.5%; P<.05). Racial/ethnic differences were found in California, with the highest prevalence among non-Hispanic Black participants (n=86, 45.5%), and in Florida, with the highest among Hispanic (n=567, 69.3%) participants (P<.05), but not in the Midwest and Louisiana. The main effect model confirmed the U-shaped association with age: strongest association with age 25-34 years (OR 2.29, 95% CI 1.74-3.01). Statistical interactions of gender and race/ethnicity with the region were significant, following the pattern found by the crude analysis. Compared to males in California, the associations with the female gender were strongest in Florida (OR=7.88, 95% CI 5.96-10.41) and Louisiana (OR=6.09, 95% CI 4.55-8.14). Compared to non-Hispanic White participants in California, the strongest associations were found with being Hispanic in Florida (OR=11.18, 95% CI 7.01-17.85) and Black in Louisiana (OR=8.94, 95% CI 5.53-14.47). However, the strongest race/ethnicity variability was observed within California and Florida: the ORs varied 4.6- and 2-fold between racial/ethnic groups in these regions, respectively. CONCLUSIONS: These findings highlight the role of local contextual factors in driving vaccine hesitancy and its demographic patterns.

The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort.

The Minority and Rural Coronavirus Insights Study (MRCIS) is an ongoing prospective cohort study examining health disparities associated with SARS-CoV-2 infection among medically underserved populations. This report describes procedures implemented to establish the MRCIS cohort and examines the factors associated with the molecular and serological assessment of SARS-CoV-2 infection status at participant enrollment. Participants were recruited from 5 geographically dispersed federally qualified health centers between November 2020 and April 2021. At baseline, participants completed a detailed demographic survey and biological samples were collected for testing. SARS-CoV-2 infection status was determined based on the combined molecular and serological test results. Chi-squared and logistic regression analyses were conducted to examine associations between sociodemographic factors, COVID-19 safety measures, existing comorbidities, and SARS-CoV-2 infection status. The final cohort included 3238 participants. The mean age of participants was 50.2 ± 15.8 years. Most participants identified as female (60.0%), heterosexual or straight (93.0%), White (47.6%), and Hispanic or Latino (49.1%). Approximately 26.1% of participants had at least one positive SARS-CoV-2 test result. The main effect model included age, sex, and race/ethnicity. Compared with adults ≥65 years, participants in all other age groups had ∼2 times increased odds of a positive SARS-CoV-2 test result. In addition, racial/ethnic minorities had ∼2 times increased odds of a positive SARS-CoV-2 infection status compared with non-Hispanic Whites. A unique cohort of a traditionally medically underserved minority population was established. Significant racial and ethnic disparities in SARS-CoV-2 infection status at baseline were discovered.

Weight changes and characteristics of patients associated with weight gain during inpatient psychiatric treatment.

This study investigated weight changes and patient characteristics associated with weight gain in a public psychiatric hospital. A retrospective chart review was conducted on a multi-racial population admitted for psychiatric inpatient treatment. Patients gained an average of 5.41 pounds during psychiatric hospitalization. Patients with normal weight at admission were significantly more likely to gain weight compared to overweight or obese patients. Black patients showed the greatest weight gain, while Asian patients showed the smallest weight gain. This study suggests that it may be possible to identify specific demographic characteristics that warrant more intensive clinical evaluation, although additional research is necessary.

Rapid Telepsychiatry Implementation During COVID-19: Increased Attendance at the Largest Health System in the United States.

OBJECTIVE: This study aimed to examine differences in completion rates between telepsychiatry and in-person visits during the COVID-19 pandemic and a prior reference period. METHODS: The authors used electronic medical record data along with chi-squared or t tests to compare patients' demographic characteristics. Generalized estimating equations for estimating the odds of primary and secondary outcomes were used, controlling for demographic characteristics. RESULTS: During COVID-19, the odds of completing a telepsychiatry visit (N=26,715) were 6.68 times the odds of completing an in-person visit (N=11,094). The odds of completing a telepsychiatry visit during COVID-19 were 3.00 times the odds of completing an in-person visit during the pre-COVID-19 reference period (N=40,318). CONCLUSIONS: In this cross-sectional study, outpatient adult mental health clinic telepsychiatry appointments, largely by telephone, were strongly associated with a higher rate of visit completion compared with in-person visits during and prior to the COVID-19 pandemic. Regulators should consider permanently enabling reimbursement for telephone-only telepsychiatry visits.

Study protocol for a pragmatic trial of the Consult for Addiction Treatment and Care in Hospitals (CATCH) model for engaging patients in opioid use disorder treatment.

BACKGROUND: Treatment for opioid use disorder (OUD) is highly effective, yet it remains dramatically underutilized. Individuals with OUD have disproportionately high rates of hospitalization and low rates of addiction treatment. Hospital-based addiction consult services offer a potential solution by using multidisciplinary teams to evaluate patients, initiate medication for addiction treatment (MAT) in the hospital, and connect patients to post-discharge care. We are studying the effectiveness of an addiction consult model [Consult for Addiction Treatment and Care in Hospitals (CATCH)] as a strategy for engaging patients with OUD in treatment as the program rolls out in the largest municipal hospital system in the US. The primary aim is to evaluate the effectiveness of CATCH in increasing post-discharge initiation and engagement in MAT. Secondary aims are to assess treatment retention, frequency of acute care utilization and overdose deaths and their associated costs, and implementation outcomes. METHODS: A pragmatic trial at six hospitals, conducted in collaboration with the municipal hospital system and department of health, will be implemented to study the CATCH intervention. Guided by the RE-AIM evaluation framework, this hybrid effectiveness-implementation study (Type 1) focuses primarily on effectiveness and also measures implementation outcomes to inform the intervention's adoption and sustainability. A stepped-wedge cluster randomized trial design will determine the impact of CATCH on treatment outcomes in comparison to usual care for a control period, followed by a 12-month intervention period and a 6- to 18-month maintenance period at each hospital. A mixed methods approach will primarily utilize administrative data to measure outcomes, while interviews and focus groups with staff and patients will provide additional information on implementation fidelity and barriers to delivering MAT to patients with OUD. DISCUSSION: Because of their great potential to reduce the negative health and economic consequences of untreated OUD, addiction consult models are proliferating in response to the opioid epidemic, despite the absence of a strong evidence base. This study will provide the first known rigorous evaluation of an addiction consult model in a large multi-site trial and promises to generate knowledge that can rapidly transform practice and inform the potential for widespread dissemination of these services. TRIAL REGISTRATION: NCT03611335.

Clinical and Psychosocial Profiles of Asian Immigrants Who Repeatedly Attempt Suicide: A Mixed-Method Study of Risk and Protective Factors.

BACKGROUND: Persons who repeatedly attempt suicide comprise a highly distressed population that warrants the understanding of risk and protective factors in assessment and treatment. There is a dearth of literature on Asian immigrants' suicidal behavior. AIMS: The study aimed to capture the clinical and psychosocial profiles of Asian immigrants who made repeated suicide attempts. METHOD: We utilized retrospective chart reviews (n = 44) and in-person interviews (n = 12) in two urban public hospitals. RESULTS: The study samples shared major suicide risk factors identified in studies of other populations. Participants of the interview sample suffered from a pervasive sense of hopelessness stemming from social isolation, self-stigma, feelings of failure in their life roles, and perceptions of rejection by their families. Conversely, psychological well-being--feeling cared for and able to reciprocate care for others--appeared to be a protective factor for participants who improved in their functioning and recovery. CONCLUSION: The study lays the groundwork for further research on suicide risk and protective factors.

Screening for type 2 diabetes mellitus in patients with mental illness: application of a self-assessment score for diabetes mellitus risk.

Various methods for diabetes risk assessment have been developed over a decade, but they were not evaluated in patients with mental illness. This study examined the feasibility and utility of a self-assessment score for type 2 diabetes mellitus (DM2) risk among patients with mental illness. DM2 risk was assessed by patients with mental illness as well as clinicians via a self-assessment questionnaire, and the resulting scores were compared to each other as well as with actual diagnosis. Of 100 patients, nine patients were newly revealed to have DM2 and 34 patients have pre-DM2. Patients tended to underreport risk factors - obesity and physical activity - so perceived to have lower risk. Sensitivity of the self-assessment score was different when used by patients and by clinicians despite correlation coefficient of 0.82. Based on positive predictive values, we may expect one out of two patients who have high scores actually have DM2 or pre-DM2. Also, the discrimination capability was reasonably high (AUC=0.79), comparable to its performance observed in general populations. The self-assessment score has potential as a simple and adjunct tool to identify a high risk group of DM2/pre-DM2 among persons with mental illness, especially, when used together with health care providers.

Reducing restraints: alternatives to restraints on an inpatient psychiatric service--utilizing safe and effective methods to evaluate and treat the violent patient.

This paper describes the violence safety program instituted at Elmhurst Hospital Center in Queens, New York City in 2001, which significantly reduced the use of restraints and seclusion department wide, while providing a safe and therapeutic environment for patient recovery. The hospital service and program instituted is described, followed by restraint and seclusion data since 1998, and the program's results through 2003. Concurrent data in areas that could be affected by a reduction in restraint and seclusion such as self-injurious behaviors and altercations; use of emergency medication; use of special observation and length of stay data are also presented. In addition, types and frequency of alternative methods utilized to avoid restraints and seclusion are described.

The safe treatment of the suicidal patient in an adult inpatient setting: a proactive preventive approach.

This paper focuses on the work of an inpatient service in an acute care safety net hospital in the prevention of suicide on its inpatient service and during the high-risk period post discharge. The strategy utilized a comprehensive proactive systems approach to the suicidal patient including: a formalized suicide assessment jointly done by medical and nursing staff, accurate diagnosis and best practice treatment, a flexible nursing observation policy, groups on inpatient units focused on suicide and key risk factors and triggers, and a communication tool to the next level of care that describes the strategies learned by the patient to deal with his or her suicidality. Incidents of self-injurious behaviors and special observation hours were monitored.