A mixed methods study of provider factors in buprenorphine treatment retention.

BACKGROUND: Low retention is a persistent challenge in the delivery of buprenorphine treatment for opioid use disorder (OUD). The goal of this study was to identify provider factors that could drive differences in treatment retention while accounting for the contribution of patient characteristics to retention. METHODS: We developed a novel a mixed-methods approach to explore provider factors that could drive retention while accounting for patient characteristics. We used Medicaid claims data from North Carolina in the United States to identify patient characteristics associated with higher retention. We then identified providers who achieved high and low retention rates. We matched high- and low-retention providers on their patients' characteristics. This matching created high- and low-retention provider groups whose patients had similar characteristics. We then interviewed providers while blinded to which belonged in the high- and low-retention groups on aspects of their practice that could affect retention rates, such as treatment criteria, treatment cost, and services offered. RESULTS: Less than half of patients achieved 180-day treatment retention with large differences by race and ethnicity. We did not find evidence that providers who achieved higher retention consistently did so by providing more comprehensive services or selecting for more stable patients. Rather, our findings suggest use of "high-threshold" clinical approaches, such as requiring participation in psychosocial services or strictly limiting dosages, explain differences in retention rates between providers whose patients have similar characteristics. All low-retention providers interviewed used a high-threshold practice compared to half of high-retention providers interviewed. Requiring patients to participate in psychosocial services, which were often paid out-of-pocket, appeared to be especially important in limiting retention. CONCLUSION: Providers who adopt low-threshold approaches to treatment may achiever higher retention rates than those who adopt high-threshold approaches. Addressing cost barriers and systemic racism are likely also necessary for improving buprenorphine treatment retention.

Appropriateness of psychiatric advance directives facilitated by peer support specialists and clinicians on Assertive Community Treatment teams.

BACKGROUND: Psychiatric advance directives (PADs) are used to document a person's treatment preferences for a future mental health crisis. Peer support specialists have been proposed to facilitate PADs, but little is known about the quality of peer versus clinician facilitated PADs. AIMS: This study examined whether PAD documents facilitated by peer specialists and non-peer clinicians differed in the mix of treatment requests and refusals and expert ratings of feasibility and consistency. METHODS: Analyses were conducted of content and expert ratings of 72 PAD documents from a randomized trial of PAD facilitation by peers and clinicians on Assertive Community Treatment (ACT) teams. A count of treatment refusals and requests was used to classify documents as predominantly prescriptive, proscriptive, or balanced. Regression was used to estimate relationships between PAD facilitator type and content. RESULTS: Peer-facilitated PADs were significantly more likely to be predominantly prescriptive than were PADs facilitated by non-peer clinicians. Prescriptive PADs were more likely to receive expert ratings of high feasibility and consistency. CONCLUSIONS: Results should alleviate some clinicians' apprehensions regarding the appropriateness of peer-facilitated PADs, such as the concern that people with lived experience with mental illness might encourage other consumers to use their PAD primarily for treatment refusals.

Differential service utilization associated with trauma-informed integrated treatment for women with co-occurring disorders.

Women with co-occurring mental health and substance use disorders and trauma histories vary greatly in symptom severity and use of support services. This study estimated differential effects of an integrated treatment intervention (IT) across sub-groups of women in this population on services utilization outcomes. Data from a national study were used to cluster participants by symptoms and service utilization, and then estimate the effect of IT versus usual care on 12-month service utilization for each sub-group. The intervention effect varied significantly across groups, in particular indicating relative increases in residential treatment utilization associated with IT among women with predominating trauma and substance abuse symptoms. Understanding how IT influences service utilization for different groups of women in this population with complex needs is an important step toward achieving an optimal balance between need for treatment and service utilization, which can ultimately improve outcomes and conserve resources.

Service Utilization Patterns as Predictors of Response to Trauma-Informed Integrated Treatment for Women With Co-occurring Disorders.

OBJECTIVE: The current study examined whether clinical responses to an integrated treatment intervention among women with co-occurring disorders and histories of abuse varied according to their service use patterns at baseline. METHODS: Data were from a national, multi-site, integrated treatment intervention study in 1998-2003. Analyses included 999 study participants assigned to the integrated treatment group and who were symptomatic at baseline. Participants' baseline service use activity was characterized according to five distinct baseline service use clusters. Logistic regression models estimated study participants' odds of good clinical responses to integrated treatment at 12 months across the five service clusters. RESULTS: Participants with high levels of psychotropic medication and medical care use at baseline had significantly lower odds than low-intensity service users of having a good response to integrated treatment at 12 months on mental health, alcohol addiction, and posttraumatic stress measures. A majority of women in this group had serious medical illness or disability and were more likely than their counterparts with other service use patterns to have used homeless or domestic violence shelters. CONCLUSIONS: Women who used high levels of medication and medical services appear to have faced especially difficult barriers in responding well to integrated treatment. Careful assessments of their mental health, trauma, and medical treatment needs may be required as part of integrated treatment in an effort to improve their response to integrated treatment, clinical outcomes and well-being. This information can also be used to target integrated treatment to women who are likely to respond positively and achieve meaningful improvements in their functioning.

Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York.

OBJECTIVE: This study examined whether persons with mental illness who undergo a period of involuntary outpatient commitment continue to receive prescribed medications and avoid psychiatric hospitalization after outpatient commitment ends. METHODS: Data on Medicaid pharmacy fills and inpatient treatment were used to describe patterns of medication possession and hospitalization for persons with mental illness after they received assisted outpatient treatment (AOT) in New York between 1999 and 2007 (N=3,576). Multivariable time-series analysis was used to compare post-AOT periods to pre-AOT periods. RESULTS: For former AOT recipients, sustained improvements in rates of medication possession and hospitalization in the post-AOT period varied according to the length of time spent in court-ordered treatment. When the court order for AOT was for six months or less, improved medication possession rates and reduced hospitalization were sustained in the post-AOT period only when intensive case coordination services (assertive community treatment, intensive case management, or both) were kept in place. However, when the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services. CONCLUSIONS: Benefits of involuntary outpatient commitment, as indicated by improved rates of medication possession and decreased hospitalizations, were more likely to persist after involuntary outpatient commitment ends if it is kept in place longer than six months.

Assessing outcomes for consumers in New York's assisted outpatient treatment program.

OBJECTIVE: This study examined whether New York State's assisted outpatient treatment (AOT) program, a form of involuntary outpatient commitment, improves a range of policy-relevant outcomes for court-ordered individuals. METHODS: Administrative data from New York State's Office of Mental Health and Medicaid claims between 1999 and 2007 were linked to examine whether consumers under a court order for AOT experienced reduced rates of hospitalization, shorter hospital stays, and improvements in other outcomes. Multivariable analyses controlling for relevant covariates were used to examine the likelihood that AOT produced these effects. RESULTS: On the basis of Medicaid claims and state reports for 3,576 AOT consumers, the likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order (odds ratio [OR]=.77, 95% confidence interval [CI]=.72-.82) and by over one-third during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, and OR=.84, CI=.81-.86, respectively). Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services. CONCLUSIONS: Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.

Robbing Peter to pay Paul: did New York State's outpatient commitment program crowd out voluntary service recipients?

OBJECTIVE: This study examined whether New York State's assisted outpatient treatment (AOT) program disadvantaged voluntary service recipients by directing services toward court-ordered individuals. METHODS: Administrative data from the New York State Office of Mental Health were linked with Medicaid claims from 1999 through 2007 to compare trends in utilization of enhanced outpatient services by involuntary and voluntary service recipients with serious mental illness. Multivariable time series analysis was used to examine the likelihood that voluntary care seekers (N=3,295) either did not initiate or did not receive assertive community treatment or intensive case management during any month as a function of the number of AOT orders in the system. RESULTS: New York State appropriated new resources for enhanced community-based mental health services to implement AOT. During the first three years of the AOT program, most of the expansion in enhanced services was directed toward individuals under court-ordered treatment, which appears to have affected voluntary care seekers by lowering their odds of initiating enhanced services and raising their odds of having these services discontinued or no longer receiving them. However, after the first three years of AOT, enhanced service provision expanded steadily among both voluntary and involuntary recipients. CONCLUSIONS: In tandem with New York's AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.

Reductions in arrest under assisted outpatient treatment in New York.

OBJECTIVE: Individuals with serious mental illness have a relatively high risk of criminal justice involvement. Assisted outpatient treatment (AOT) is a legal mechanism that mandates treatment for individuals with serious mental illness who are unlikely to live safely in the community without supervision and who are also unlikely to voluntarily participate in treatment. Under an alternative arrangement, some individuals for whom an AOT order is pursued sign a voluntary service agreement in lieu of a formal court order. This study examined whether AOT recipients have lower odds of arrest than persons with serious mental illness who have not yet initiated AOT or signed a voluntary service agreement. METHODS: Interview data from 2007 to 2008 from an evaluation of AOT in New York State were matched with arrest records from 1999 to 2008 for 181 individuals and analyzed using multivariable logistic regression. RESULTS: The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (OR=.39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement. The odds of arrest among individuals currently under a voluntary service agreement (OR=.64) were not significantly different than for individuals who had not yet initiated either arrangement. The adjusted predicted probabilities of arrest in any given month were 3.7% for individuals who had not yet initiated AOT or a voluntary agreement, 1.9% for individuals currently on AOT, and 2.8% for individuals currently under a voluntary agreement. CONCLUSIONS: AOT may be an important part of treatment efforts to reduce criminal justice involvement among people with serious mental illness.

Barriers to the adoption and implementation of preventive dental services in primary medical care.

OBJECTIVE: To determine the barriers to adopting preventive oral health procedures in medical primary care. METHODS: Medical providers who participated in a Medicaid demonstration in North Carolina completed questionnaires reporting their experiences with providing preventive dental services for children from birth to 3 years of age. Eleven factors were established as possible obstacles to the adoption of an oral health program. After 12 months of participation in the Into the Mouths of Babes training program, providers (N = 231) from 49 pediatric practices and 28 family physician practices reported if any of the 11 factors had been an obstacle to adoption and, if so, whether these obstacles were overcome. Program adoption and implementation, defined as providing all of the services on a regular basis, were predicted by using logistic regression to analyze the responses from providers who reported 1 or more barriers, the number of barriers identified (knowledge, attitudes, and external factors), and the number that were overcome. RESULTS: Program-adoption rates were high, with 70.3% of the participants providing dental services on a routine basis. Attitude and external factors were positively associated with adoption, particularly with difficulty in applying the varnish, integration of the dental procedures into practice, resistance among staff and colleagues, and dentist referral difficulties. From 40.4% to 61.5% of providers overcame these 4 most common barriers. Those who reported external barriers and were unable to overcome them were less likely to provide the services, compared with those providers who reported no barriers (odds ratio: 0.08 [95% confidence interval: 0.01-0.44]). CONCLUSIONS: The number of barriers to adopting preventive dental procedures in primary care medical practices is associated with implementation. A large proportion of these barriers can be overcome, leading to high adoption rates in a short amount of time. The barriers to adoption are similar to those identified in the literature on changing patient care, with the unique aspects of fluoride application to teeth. Interventions to promote preventive dental care in medical settings should rely heavily on empirical literature. Training physicians in preventive dentistry should identify and target potential barriers with information and options for introducing office-based systems to improve the chances of adoption.

Psychiatric advance directives and reduction of coercive crisis interventions.

BACKGROUND: Psychiatric advance directives are intended to enable self-determined treatment for patients who lose decisional capacity, and thus reduce the need for coercive interventions such as police transport, involuntary commitment, seclusion and restraints, and involuntary medications during mental health crises; whether PADs can help prevent the use of these interventions in practice is unknown. AIMS: This study examined whether completion of a Facilitated Psychiatric Advance Directive (F-PAD) was associated with reduced frequency of coercive crisis interventions. METHOD: The study prospectively compared a sample of PAD completers (n=147) to non-completers (n=92) on the frequency of any coercive interventions, with follow-up assessments at 6, 12, and 24 months. Repeated-measures multiple regression analysis was used to estimate the effect of PADs. Models controlled for relevant covariates including a propensity score for initial selection to PADs, baseline history of coercive interventions, concurrent global functioning and crisis episodes with decisional incapacity. RESULTS: F-PAD completion was associated with lower odds of coercive interventions (adjusted OR=0.50; 95% CI=0.26-0.96; p < 0.05). CONCLUSIONS: PADs may be an effective tool for reducing coercive interventions around incapacitating mental health crises. Less coercion should lead to greater autonomy and self-determination for people with severe mental illness.