Use of in-network insurance benefits is critical for improving retention in telehealth-based buprenorphine treatment.

An empiric evidence base is lacking regarding the relationship between insurance status, payment source, and outcomes among patients with opioid use disorder (OUD) on telehealth platforms. Such information gaps may lead to unintended impacts of policy changes. Following the phase-out of the COVID-19 Public Health Emergency, states were allowed to redetermine Medicaid eligibility and disenroll individuals. Yet, financial barriers remain a common and significant hurdle for patients with OUD and are associated with worse outcomes. We studied 3842 patients entering care in 2022 at Ophelia Health, one of the nation's largest OUD telehealth companies, to assess associations between insurance status and 6-month retention. In multivariable analyses, in-network patients who could use insurance benefits were more likely to be retained compared with cash-pay patients (adjusted risk ratio [aRR]: 1.50; 95% CI: 1.40-1.62; P < .001). Among a subsample of 882 patients for whom more detailed insurance data were available (due to phased-in electronic health record updates), in-network patients were also more likely to be retained at 6 months compared with insured, yet out-of-network patients (aRR: 1.86; 95% CI: 1.54-2.23; P < .001). Findings show that insurance status, and specifically the use of in-network benefits, is associated with superior retention and suggest that Medicaid disenrollment and insurance plan hesitation to engage with telehealth providers may undermine the nation's response to the opioid crisis.

Care Fragmentation, Care Continuity, and Care Coordination-How They Differ and Why It Matters.

This Viewpoint considers why fragmentation occurs and suggests a potential path forward for developing evidenced-based strategies that can reduce the occurrence of fragmentation and its associated harms.

Providing Behavioral Health Care in PACE - A Review of Federal and State Manual Regulations.

OBJECTIVES: Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH). DESIGN: Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains. SETTING AND PARTICIPANTS: The 155 PACE organizations operating in 32 states and the District of Columbia. METHODS: A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals. RESULTS: According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions. CONCLUSIONS AND IMPLICATIONS: Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

The Evolve to Next-Gen ACT Network: An evolving open-access, real-world data resource primed for real-world evidence research across the Clinical and Translational Science Award Consortium.

The ACT Network was funded by NIH to provide investigators from across the Clinical and Translational Science Award (CTSA) Consortium the ability to directly query national federated electronic health record (EHR) data for cohort discovery and feasibility assessment of multi-site studies. NIH refunded the program for expanded research application to become "Evolve to Next-Gen ACT" (ENACT). In parallel, the US Food and Drug Administration has been evaluating the use of real-world data (RWD), including EHR data, as sources of real-world evidence (RWE) for its regulatory decisions involving drug and biological products. Using insights from implementation science, six lessons learned from ACT for developing and sustaining RWD/RWE infrastructures and networks across the CTSA Consortium are presented in order to inform ENACT's development from the outset. Lessons include intentional institutional relationship management, end-user engagement, beta-testing, and customer-driven adaptation. The ENACT team is also conducting customer discovery interviews with CTSA hub and investigators using Innovation-Corps@NCATS (I-Corps™) methodology for biomedical entrepreneurs to uncover unmet RWD needs. Possible ENACT value proposition hypotheses are presented by stage of research. Developing evidence about methods for sustaining academically derived data infrastructures and support can advance the science of translation and support our nation's RWD/RWE research capacity.

Behavioral health integration in the Program of All-Inclusive Care for the Elderly (PACE): A scoping review.

BACKGROUND: The Program of All-inclusive Care for the Elderly (PACE) is a community-based care model that delivers collaborative care via an interdisciplinary team to meet the medical and social needs of older adults eligible for nursing home placement. Fifty-nine percent of PACE participants are reported to have at least one psychiatric disorder. PACE organizations (POs) function through an interdisciplinary model of care, but a behavioral health (BH) provider is not a mandated role on the interdisciplinary team. Published literature regarding how POs integrate and provide BH services is limited; however, the National PACE Association (NPA) and select POs have made significant contributions to behavioral health integration (BHI) efforts in PACE. METHODS: PubMED, EMBASE, and PsycINFO were searched for articles published between January 2000 and June 2022; hand-searching was also conducted. Research articles and items involving BH components or programming in POs were included. Evidence of BH programming and initiatives at the organization and national level was summarized. RESULTS: This review reported on nine primary items addressing BH in POs from 2004 to 2022. It found evidence of successful BH initiatives in PACE and identified a gap of published information given an evident need for BH services in the PACE participant population. Findings also indicate the NPA works to advance BH integration in POs with a dedicated workgroup that has produced the NPA BH Toolkit, BH training webinar series, and a site coaching program. CONCLUSIONS: In the absence of PACE-specific BH delivery guidelines and guidance from the federal or state level for PACE programs, BH service inclusion has been developed unevenly across POs. Assessing the landscape of BH inclusion across POs is a step toward evidence-based and standardized inclusion of BH within the all-inclusive care model.

Racial differences in COVID-19 severity associated with history of substance use disorders and overdose: Findings from multi-site electronic health records in New York City.

Substance use disorders (SUD) are associated with increased risk of worse COVID-19 outcomes. Likewise, racial/ethnic minority patients experience greater risk of severe COVID-19 disease compared to white patients. Providers should understand the role of race and ethnicity as an effect modifier on COVID-19 severity among individuals with SUD. This retrospective cohort study assessed patient race/ethnicity as an effect modifier of the risk of severe COVID-19 disease among patients with histories of SUD and overdose. We used merged electronic health record data from 116,471 adult patients with a COVID-19 encounter between March 2020 and February 2021 across five healthcare systems in New York City. Exposures were patient histories of SUD and overdose. Outcomes were risk of COVID-19 hospitalization and subsequent COVID-19-related ventilation, acute kidney failure, sepsis, and mortality. Risk factors included patient age, sex, and race/ethnicity, as well as medical comorbidities associated with COVID-19 severity. We tested for interaction between SUD and patient race/ethnicity on COVID-19 outcomes. Findings showed that Non-Hispanic Black, Hispanic/Latino, and Asian/Pacific Islander patients experienced a higher prevalence of all adverse COVID-19 outcomes compared to non-Hispanic white patients. Past-year alcohol (OR 1.24 [1.01-1.53]) and opioid use disorders (OR 1.91 [1.46-2.49]), as well as overdose history (OR 4.45 [3.62-5.46]), were predictive of COVID-19 mortality, as well as other adverse COVID-19 outcomes. Among patients with SUD, significant differences in outcome risk were detected between patients of different race/ethnicity groups. Findings indicate that providers should consider multiple dimensions of vulnerability to adequately manage COVID-19 disease among populations with SUDs.

The impact of preexisting psychiatric disorders and antidepressant use on COVID-19 related outcomes: a multicenter study.

Pre-existing mental disorders are linked to COVID-19-related outcomes. However, the findings are inconsistent and a thorough analysis of a broader spectrum of outcomes such as COVID-19 infection severity, morbidity, and mortality is required. We investigated whether the presence of psychiatric diagnoses and/or the use of antidepressants influenced the severity of the outcome of COVID-19. This retrospective cohort study evaluated electronic health records from the INSIGHT Clinical Research Network in 116,498 individuals who were diagnosed with COVID-19 between March 1, 2020, and February 23, 2021. We examined hospitalization, intubation/mechanical ventilation, acute kidney failure, severe sepsis, and death as COVID-19-related outcomes. After using propensity score matching to control for demographics and medical comorbidities, we used contingency tables to assess whether patients with (1) a history of psychiatric disorders were at higher risk of more severe COVID-19-related outcomes and (2) if use of antidepressants decreased the risk of more severe COVID-19 infection. Pre-existing psychiatric disorders were associated with an increased risk for hospitalization, and subsequent outcomes such as acute kidney failure and severe sepsis, including an increased risk of death in patients with schizophrenia spectrum disorders or bipolar disorders. The use of antidepressants was associated with significantly reduced risk of sepsis (p = 0.033), death (p = 0.026). Psychiatric disorder diagnosis prior to a COVID-19-related healthcare encounter increased the risk of more severe COVID-19-related outcomes as well as subsequent health complications. However, there are indications that the use of antidepressants might decrease this risk. This may have significant implications for the treatment and prognosis of patients with COVID-19.

ICD-11: A catalyst for advancing patient safety surveillance globally.

The World Health Organization's (WHO) international classification of disease version 11 (ICD-11) contains several features which enable improved classification of patient safety events. We have identified three suggestions to facilitate adoption of ICD-11 from the patient safety perspective. One, health system leaders at national, regional, and local levels should incorporate ICD-11 into all approaches to monitor patient safety. This will allow them to take advantage of the innovative patient safety classification methods embedded in ICD-11 to overcome several limitations related to existing patient safety surveillance methods. Two, application developers should incorporate ICD-11 into software solutions. This will accelerate adoption and utility of software-enabled clinical and administrative workflows relevant to patient safety management. This is enabled as a result of the ICD-11 application programming interface (or API) developed by the WHO. Third, health system leaders should adopt the ICD-11 using a continuous improvement framework. This will help leaders at national, regional and local levels to take advantage of specific existing initiatives which will be strengthened by ICD-11, including peer review comparisons, clinician engagement, and alignment of front-line safety efforts with post marketing surveillance of medical technologies. While the investment to adopt ICD-11 will be considerable, these will be offset by reducing the ongoing costs related to a lack of accurate routine information.

COVID-19 complications among patients with opioid use disorder: a retrospective cohort study across five major NYC hospital systems.

BACKGROUND AND AIMS: Individuals with opioid use disorder (OUD) suffer disproportionately from COVID-19. To inform clinical management of OUD patients, research is needed to identify characteristics associated with COVID-19 progression and death among this population. We aimed to investigate the role of OUD and specific comorbidities on COVID-19 progression among hospitalized OUD patients. DESIGN: Retrospective cohort study of merged electronic health records (EHR) from five large private health systems. SETTING: New York City, New York, USA, 2011-21. PARTICIPANTS: Adults with a COVID-19 encounter and OUD or opioid overdose diagnosis between March 2020 and February 2021. MEASUREMENTS: Primary exposure included diagnosis of OUD/opioid overdose. Risk factors included age, sex, race/ethnicity and common medical, substance use and psychiatric comorbidities known to be associated with COVID-19 severity. Outcomes included COVID-19 hospitalization and subsequent intubation, acute kidney failure, severe sepsis and death. FINDINGS: Of 110 917 COVID-19+ adults, 1.17% were ever diagnosed with OUD/opioid overdose. OUD patients had higher risk of COVID-19 hospitalization [adjusted risk ratio (aRR) = 1.40, 95% confidence interval (CI) = 1.33, 1.47], intubation [adjusted odds ratio (aOR) = 2.05, 95% CI = 1.74, 2.42], kidney failure (aRR = 1.51, 95% CI = 1.34, 1.70), sepsis (aRR = 2.30, 95% CI = 1.88, 2.81) and death (aRR = 2.10, 95% CI = 1.84, 2.40). Among hospitalized OUD patients, risks for worse COVID-19 outcomes included being male; older; of a race/ethnicity other than white, black or Hispanic; and having comorbid chronic kidney disease, diabetes, obesity or cancer. Protective factors included having asthma, hepatitis-C and chronic pain. CONCLUSIONS: Opioid use disorder patients appear to have a substantial risk for COVID-19-associated morbidity and mortality, with particular comorbidities and treatments moderating this risk.

Psychotropic Medication Use in United States Pediatric Emergency Department Visits.

OBJECTIVE AND BACKGROUND: Little is known about pediatric psychotropic medication use in the emergency department (ED), despite a rise in mental and behavioral health visits. This study describes psychotropic medication use in a nationally representative sample of pediatric mental and behavioral health ED visits over a 14-year period. METHODS: We conducted a cross-sectional analysis of pediatric (6-17 years) mental and behavioral health ED visits using the National Hospital Ambulatory Medical Care Survey, 2006-2019. We describe administration of psychotropic medications by medication type, diagnosis, and over time. Using multivariable survey-weighted logistic regression, we examine associations between medication administration and sociodemographics. RESULTS: A psychotropic medication was administered in 11.4% of the estimated 11,792,860 pediatric mental and behavioral health ED visits in our sample. Benzodiazepines were administered most frequently (4.9% of visits). Visits with anxiety disorders had the highest frequency of psychotropic medication use (26.7%). Visits by Black non-Hispanic patients had a 60% decreased odds of medication administration compared to visits for White non-Hispanic patients. Visits with public compared to private insurance had a 3.5 times increased odds of psychotropic polypharmacy. The proportion of visits in which a psychotropic medication was administered did not change statistically over time. CONCLUSIONS: A psychotropic medication was administered in 1 in 10 pediatric mental and behavioral health ED visits. Use differed by sociodemographics but did not change over time. As more youth seek mental and behavioral health care in the ED, we must better understand appropriate medication use to ensure quality and equitable care.

Value-Based Payment and Behavioral Health.

This Viewpoint discusses behavioral health and its transition to value-based payment models.

Availability and Accessibility of Mental Health Services in New York City.

Mental health services are critical components of public health infrastructure that provide essential supports to people living with psychiatric disorders. In a typical year, about 20 percent of people will have a psychiatric disorder, and about 5 percent will experience serious psychological distress, indicating a potentially serious mental illness. Nationally, the use of mental health services is low, and the use of care is not equitably distributed. In the United States as a whole and in New York City (NYC), non-Hispanic white individuals are more likely to use mental health services than non-Hispanic black individuals or Hispanic individuals. The challenges of ensuring the availability of mental health services for all groups in NYC are particularly acute, given the size of the population and its diversity in income, culture, ethnicity, and language. Adding to these underlying challenges, the coronavirus disease 2019 (COVID-19) pandemic has disrupted established patterns of care. To advance policy strategy for addressing gaps in the mental health services system, RAND researchers investigate the availability and accessibility of mental health services in NYC. The RAND team used two complementary approaches to address these issues. First, the team conducted interviews with a broad group of professionals and patients in the mental health system to identify barriers to care and potential strategies for improving access and availability. Second, the team investigated geographic variations in the availability of mental health services by compiling and mapping data on the locations and service characteristics of mental health treatment facilities in NYC.

Optimizing the Role of Military Behavioral Health Technicians: A Survey of Behavioral Health Technicians and Mental Health Providers.

Behavioral health technicians (BHTs), who are enlisted service members with the technical training to work alongside licensed mental health providers (MHPs), are an important part of the Military Health System (MHS) workforce. However, each service branch has different training requirements for BHTs, making it difficult to identify common qualifications across the BHT workforce and ensure that the MHS is making the best use of their skills. Building on prior RAND research that found inconsistencies in how BHTs were integrated across the force, researchers conducted what might be the largest survey to date of BHTs and MHPs. The results provide insights on BHTs' practice patterns, training and supervisory needs, and job satisfaction, as well as barriers to better integrating BHTs into clinical practice and steps that the MHS could take to optimize BHTs' contributions to the health and readiness of the force. Posing parallel sets of questions to BHTs and MHPs allowed comparisons of these groups' perspectives on these topics. The results revealed differences in views by service branch, time in practice, deployment history, and other characteristics. The researchers drew on these findings and recommendations to identify opportunities to optimize the BHT role.

Coding mechanisms for diagnosis timing in the International Classification of Diseases, Version 11.

BACKGROUND: Diagnoses that arise after admission are of interest because they can represent complications of health care, acute conditions arising de novo, or acute decompensation of a chronic comorbidity occurring during the hospital stay. Three countries in the world have adopted diagnosis timing codes for a number of years. Their experience demonstrates the feasibility and utility of associating an International Classification of Diseases, Version 9 or International Classification of Diseases, Version 10 diagnostic code with information on diagnosis timing, either as part of a diagnostic field or as a separate field. However, diagnosis timing is not an integrated feature of these two classifications as it will be for International Classification of Diseases, Version 11. METHODS: We examine the different types of diagnosis timing that can be used to describe complex patients and present examples of how the new International Classification of Diseases, Version 11 codes may be used. RESULTS: Extension codes are one of the important new features of International Classification of Diseases, Version 11 and allow more specificity in diagnosis timing. CONCLUSION: Imbedded and standardized diagnosis timing information is possible within the International Classification of Diseases, Version 11 classification system.

Critical Care Clinicians' Experiences of Patient Safety During the COVID-19 Pandemic.

OBJECTIVE: It is unknown how hospital- and systems-level factors have impacted patient safety in the intensive care unit (ICU) during the COVID-19 pandemic. We sought to understand how the pandemic has exacerbated preexisting patient safety issues and created novel patient safety challenges in ICUs in the United States. METHODS: We performed a national, multi-institutional, mixed-methods survey of critical care clinicians to elicit experiences related to patient safety during the pandemic. The survey was disseminated via email through the Society of Critical Care Medicine listserv. Data were reported as valid percentages, compared by COVID caseload and peak of the pandemic; free-text responses were analyzed and coded for themes. RESULTS: We received 335 survey responses. On general patient safety, 61% felt that conditions were more hazardous when compared with the prepandemic period. Those who took care of mostly COVID-19 patients were more likely to perceive that care was more hazardous (odds ratio, 4.89; 95% CI, 2.49-9.59) compared with those who took care of mostly non-COVID-19 or no COVID-19 patients. In free-text responses, providers identified patient safety risks related to pandemic adaptations, such as ventilator-related lung injury, medication and diagnostic errors, oversedation, oxygen device removal, and falls. CONCLUSIONS: Increased COVID-19 case burden was significantly associated with perceptions of a less safe patient care environment by frontline ICU clinicians. Results of the qualitative analysis identified specific patient safety hazards in ICUs across the United States as downstream consequences of hospital and provider strain during periods of the COVID-19 pandemic.

Readiness of Soldiers and Adult Family Members Who Receive Behavioral Health Care: Identifying Promising Outcome Metrics.

Behavioral health (BH) conditions-such as posttraumatic stress disorder, depression, and anxiety-are the second most common medical reasons for nondeployability in the U.S. Army. The authors of this report aimed to identify promising metrics to assess readiness among soldiers and adult family members who receive BH care. These metrics would expand the Army's outcome monitoring, which currently includes symptom improvement metrics, for patients who received BH care. The authors developed rigorous criteria to evaluate candidate readiness metrics, conducted interviews with stakeholders (Army subject-matter experts and BH providers), reviewed existing sources of data that could support the development of a readiness metric, and conducted a literature review to identify instruments that have been used to measure readiness-related domains in both military and civilian populations. The authors found that no existing data source or patient self-report instrument met criteria for implementation of a readiness metric for soldiers, but one instrument, the Walter Reed Functional Impairment Scale (WRFIS), is promising. No existing data source or patient self-report instrument met criteria for Army-wide implementation of a readiness metric for adult family members. Stakeholders reported that psychiatric symptoms, diagnosis, treatment, and impaired functioning are important indicators of lack of readiness among soldiers and adult family members. BH providers reported variability in assessing readiness and applying profiles, but behavioral experts provided suggestions for improving readiness assessment. The authors recommend that the Army conduct a pilot evaluation of a soldier readiness metric based on the WRFIS and increase standardization in applying profiles by continuing provider training.

Military Behavioral Health Staff Perspectives on Telehealth Following the Onset of the COVID-19 Pandemic.

The COVID-19 pandemic prompted sweeping changes to behavioral health care delivery in the Military Health System (MHS), which turned to telehealth to minimize disruptions and ensure continuity of care for service members. Four to seven months into the pandemic, MHS behavioral health staff at ten military treatment facilities shared their experiences using telehealth and their perspectives on its utility, barriers to its wider integration in the MHS, and concerns about its use in the post-pandemic future. Telehealth use was previously low across the MHS, but it increased dramatically with the onset of the pandemic. At the time they were interviewed, nearly all providers who treated service members with posttraumatic stress disorder, depression, or substance use disorders were using audio-only telehealth in some capacity. Although most were not using video telehealth, three-quarters expressed an openness to using it in the future. However, the widespread integration of telehealth in the MHS will need to include efforts to overcome technical and administrative barriers and to address provider concerns about telehealth modalities for behavioral health care delivery-for example, the need for clinical guidance on using telehealth with specific types of patients, and provider and patient orientation on using telehealth technology.

Opioid use disorder Cascade of care framework design: A roadmap.

Unintentional overdose deaths, most involving opioids, have eclipsed all other causes of US deaths for individuals less than 50 years of age. An estimated 2.4 to 5 million individuals have opioid use disorder (OUD) yet a minority receive treatment in a given year. Medications for OUD (MOUD) are the gold standard treatment for OUD however early dropout remains a major challenge for improving clinical outcomes. A Cascade of Care (CoC) framework, first popularized as a public health accountability strategy to stem the spread of HIV, has been adapted specifically for OUD. The CoC framework has been promoted by the NIH and several states and jurisdictions for organizing quality improvement efforts through clinical, policy, and administrative levers to improve OUD treatment initiation and retention. This roadmap details CoC design domains based on available data and potential linkages as individual state agencies and health systems typically rely on limited datasets subject to diverse legal and regulatory requirements constraining options for evaluations. Both graphical decision trees and catalogued studies are provided to help guide efforts by state agencies and health systems to improve data collection and monitoring efforts under the OUD CoC framework.