Clinical and financial outcome impacts of comprehensive geriatric assessment in a level 1 geriatric emergency department.

BACKGROUND: The aging population has led to an increase in emergency department (ED) visits by older adults who have complex medical conditions and high social needs. The purpose of this study was to assess if comprehensive geriatric evaluation and management impacted service utilization and cost by older adults admitted to the ED. METHODS: This is a retrospective matched case-control study at a level 1 geriatric ED (GED) from January 1, 2018-March 31, 2020. Geriatric nurse specialists (GENIEs) provided comprehensive evaluations and management for GED patients. Propensity score matching was used to match patients receiving GENIE consultations to ED patients who did not receive a GENIE consult. Regression was used to assess the impact of the GENIE services on inpatient admissions, ED revisits and cost of inpatient and ED care from the payor perspective. RESULTS: GENIE consults were associated with a 13.0% reduction in absolute risk of admission through the ED at index (95% confidence interval [CI] -17.0%, -9.0%, p < 0.001) and a reduction in risk for total admissions at 30 and 90-days post discharge (-11.3%, 95% CI -15.6%, -7.1%, p-value < 0.001; and -10.0, 95% CI -13.8%, -6.0%; p < 0.001 respectively), both driven by reduced risk of admission at the index visit. GENIE consults were associated with a 4% increase in absolute risk of revisits to the ED within 30 days (95% CI 0.6%, 7.3%; p = 0.001). GENIE consults were associated with a decrease in cost of inpatient and ED care, with savings of $2344 within 30 days (95% CI $2247, $2441, p < 0.001) and savings of $2004 USD within 90 days (95% CI $1895, $2114, p < 0.001), driven by reduced costs at the index visit. CONCLUSIONS: GENIE consults were associated with decreased inpatient admissions through the ED, modestly increased ED revisits, and decreased cost of inpatient and ED care. The results of this study can be useful for EDs considering approaches to better serve older adults. They can also be of interest to payers as an area of potential cost savings.

Programmatic Support for Peer Specialists that Serve Transition Age Youth Living with Serious Mental Illness: Perspectives of Program Managers from Two Southern California Counties.

Peer Specialists (PS) often work in outpatient mental health programs serving transition age youth (TAY). This study examines program managers' perspectives on efforts to strengthen PS' professional development. In 2019, we interviewed program managers (n = 11) from two Southern California Counties employed by public outpatient mental health programs (n = 8) serving TAY and conducted thematic analyses. We present themes and illustrative quotes. PS' roles are highly flexible; thus, PM support PS to strengthen skills to address organization-facing and client-facing responsibilities. PM addressed time management, documentation, PS integration into the organization, and workplace relationships. Trainings to better support clients included addressing cultural competency to serve LGBTQ TAY and racial/ethnic subgroups. Diverse supervision modalities address PS' diverse needs. Supporting PS' technical and administrative skills (e.g., planning, interpersonal communication skills) may aid their implementation of a complex role. Longitudinal research can examine the impact of organizational supports on PS' job satisfaction, career trajectories, and TAY clients' engagement with services.

Barriers to Accessing Mental Health Care Under the Mental Health Services Act: A Qualitative Case Study in Orange County, California.

Despite progress made under California's Mental Health Services Act, limited access to care for cultural and linguistic minority groups remains a serious issue in community mental health. In this qualitative study we report findings from a large-scale community-level assessment that explored barriers to accessing care from the perspectives of multiple stakeholders including county advisors, advocates, community members, and consumers representing a range of cultural and linguistic communities in Orange County, California. We conducted 14 focus groups with N = 112 participants. Qualitative analysis revealed that system fragmentation, limited availability of linguistically appropriate care, and stigma continue to undermine access to mental health care. Peer health navigation and culturally responsive peer support are potential ways to promote service engagement with persons from cultural and linguistic minority groups that encounter barriers when accessing mental health services.

Clients' Perspectives Regarding Peer Support Providers' Roles and Support for Client Access to and Use of Publicly Funded Mental Health Programs Serving Transition-Age Youth in Two Southern California Counties.

Peer providers are increasingly used by mental health programs to engage transition age youth (TAY, age 16-24) living with serious mental illness. This study elicited TAY clients' perspectives on peer providers' roles, responsibilities, and contribution to TAYs' use of mental health services. In 2019, six focus groups were conducted with TAY clients (n=24) receiving publicly funded mental health services in Southern California. Results from this analysis included four themes that illustrated the role of peers as perceived by TAY clients, including: 1) building client-peer provider relationships, 2) engaging with mental health services, 3) role-modelling recovery and supporting skill acquisition to instill hope and empowerment, and 4) peer roles and experiences specific to racial/ethnic concordance. These findings provide needed perspectives on the evolving role of peer providers in mental health services programming for TAY clients.

Dulce Digital-Me: protocol for a randomized controlled trial of an adaptive mHealth intervention for underserved Hispanics with diabetes.

BACKGROUND: By 2034, the number of US individuals with diabetes is predicted to increase from 23.7 to 44.1 million, and annual diabetes-related spending is expected to grow from $113 to $336 billion. Up to 55% of US Hispanics born in the year 2000 are expected to develop diabetes during their lifetime. Poor healthcare access and cultural barriers prevent optimal care, adherence, and clinical benefit, placing Hispanics at disproportionate risk for costly diabetes complications. Mobile technology is increasingly prevalent in all populations and can circumvent such barriers. Our group developed Dulce Digital, an educational text messaging program that improved glycemic control relative to usual care. Dulce Digital-Me (DD-Me) has been tailored to a participant's individual needs with a greater focus on health behavior change. METHODS: This is a three-arm, parallel group, randomized trial with equal allocation ratio enrolling Hispanic adults with low income and poorly managed type 2 diabetes (N = 414) from a San Diego County Federally Qualified Health Center. Participants are randomized to receive Dulce Digital, Dulce Digital-Me-Automated, or Dulce Digital-Me-Telephonic. The DD-Me groups include Dulce Digital components plus personalized goal-setting and feedback delivered via algorithm-driven automated text messaging (DD-Me-Automated) or by the care team health coach (DD-Me-Telephonic) over a 12-month follow-up period. The study will examine the comparative effectiveness of the three groups in improving diabetes clinical control [HbA1c, primary outcome; low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP)] and patient-provider communication and patient adherence (i.e., medication, self-management tasks) over 12 months and will examine cost-effectiveness of the three interventions. DISCUSSION: Our comparative evaluation of three mHealth approaches will elucidate how technology can be integrated most effectively and efficiently within primary care-based chronic care model approaches to reduce diabetes disparities in Hispanics and will assess two modes of personalized messaging delivery (i.e., automated messaging vs. telephonic by health coach) to inform cost and acceptability. TRIAL REGISTRATION: NCT03130699-All items from the WHO Trial Registration data set are available in https://clinicaltrials.gov/ct2/show/study/NCT03130699 .

Developing trauma resilient communities through community capacity-building.

BACKGROUND: Trauma is a significant public health issue, negatively impacting a range of health outcomes. Providers and administrators in public mental health systems recognize the widespread experience of trauma, as well as their limited ability to address trauma within their communities. In response, the Los Angeles County Department of Mental Health funded nine regionally based community partnerships to build capacity to address trauma. We describe partnership and community capacity-building efforts and examine community impact, defined as successful linkages to resources and changes in stress tolerance capacities among community members. METHODS: We conceptualized community capacity-building as dissemination of trauma-informed education and training, community outreach and engagement, and linkage of community members to resources. We measured trauma-informed trainings among partnership members (N = 332) using the Trauma-Informed Organizational Toolkit. Outreach, engagement and linkages were documented using Event and Linkage Trackers. We examined changes in the type of successful linkage after the issuance of statewide mandatory restrictions in response to COVID-19. We examined changes in stress tolerance capacities among community members (N = 699) who were engaged in ongoing partnership activities using the 10-item Conner-Davidson Resilience Scale; the 28-item Coping Orientation to Problems; and the pictorial Inclusion of Community in Self Scale. RESULTS: Training and education opportunities were widespread: 66% of members reported opportunities for training in 13 or more trauma-informed practices. Partnerships conducted over 7800 community capacity-building events with over 250,000 attendees. Nearly 14,000 successful linkages were made for a wide range of resources, with consistent linkage success prior to (85%) and during (87%) the pandemic. In response to COVID-19, linkage type significantly shifted from basic services and health care to food distribution (p < .01). Small but significant improvements occurred in coping through emotional and instrumental support; and sense of community connectedness (p < .05 each). CONCLUSIONS: Community-based partnerships demonstrated effective capacity-building strategies. Despite the pandemic, community members did not report reduced stress tolerance, instead demonstrating gains in external help-seeking (use of emotional and instrumental supports) and perception of community connectedness. Future work will use qualitative methods to examine the impact of community capacity-building and the sustainability of this approach for addressing the impact of trauma within communities.

Oral Corticosteroids and Risk of Preterm Birth in the California Medicaid Program.

BACKGROUND: There is limited information regarding the impact of dose and gestational timing of oral corticosteroid (OCS) use on preterm birth (PTB), especially among women with asthma. OBJECTIVES: To evaluate OCS dose and timing on PTB for asthma and, as a comparison, systemic lupus erythematosus (SLE). METHODS: We used health care data from California Medicaid enrollees linked to birth certificates (2007-2013), identifying women with asthma (n = 22,084) and SLE (n = 1174). We estimated risk ratios (RR) for OCS cumulative dose trajectories and other disease-related medications before gestational day 140 and hazard ratios (HR) for time-varying exposures after day 139. RESULTS: For asthma, PTB risk was 14.0% for no OCS exposure and 14.3%, 16.8%, 20.5%, and 32.7% in low, medium, medium-high, and high cumulative dose trajectory groups, respectively, during the first 139 days. The high-dose group remained associated with PTB after adjustment (adjusted RR [aRR]: 1.46; 95% confidence interval [CI]: 1.00, 2.15). OCS dose after day 139 was not clearly associated with PTB, nor were controller medications. For SLE, PTB risk for no OCS exposure was 24.9%, and it was 39.1% in low- and 61.2% in high-dose trajectory groups. aRR were 1.80 (95% CI: 1.34, 2.40) for high and 1.24 (95% CI: 0.97, 1.58) for low groups. Only prednisone equivalent dose >20 mg/day after day 139 was associated with increased PTB (adjusted HR: 2.54; 95% CI: 1.60, 4.03). CONCLUSIONS: For asthma, higher OCS doses early in pregnancy, but not later, were associated with increased PTB. For SLE, higher doses early and later in pregnancy were associated with PTB.

The Availability of Peer Support and Disparities in Outpatient Mental Health Service Use Among Minority Youth with Serious Mental Illness.

We examine whether the availability of peer support reduces disparities in service use among minority youth ages 16-24 with serious mental illness in Los Angeles and San Diego Counties. Administrative data from 2015-2018 was used to summarize service use among 13,363 transition age youth age 16-24 with serious mental illness who received services from 183 outpatient public mental health programs; 17.2% were Black, 67.4% were Latinx, and 15.4% were non-Latinx white. The availability of peer support was assessed via a program survey. Generalized linear models were used to assess the relationship between availability of peer support, defined as having a peer specialist on staff, and the annual number of outpatient mental health visits. We also examined the relationship between racial/ethnic concordance of youth and peer specialists and use of outpatient services. Forty-six percent of youth received services from programs that employed peer specialists. Among youth in both counties, the availability of peer support was associated with an increase in annual outpatient visits (P ≤ .05 each). Peer support was associated with reductions in service use disparities among Black and Latinx youth in Los Angeles County (P < .001 each). Peer concordance was associated with an increase in outpatient service use among Latinx youth in both counties (P < .05 each). Peer support was associated with increases in use of outpatient mental health services. Detailed examination of the context for youth peer support implementation is merited to identify the specific pathways that improve outcomes.

Roles of peer specialists and use of mental health services among youth with serious mental illness.

AIM: To examine whether roles of peer specialists affect service use among Black, Latinx and White youth ages 16-24 with serious mental illness (SMI) in Los Angeles and San Diego Counties. METHODS: Administrative data from 2015 to 2018 was used to summarize service use among 6329 transition age youth age 16-24 with SMI who received services from 76 outpatient public mental health programs with peer specialists on staff. Roles of peer specialists were assessed via a program survey. Generalized linear models were used to assess the relationship between peer specialist characteristics and service use outcomes (ie, outpatient and inpatient). RESULTS: Having a transition age youth peer specialist on staff (vs older peer specialists) and having peer specialists that provide four or more services (vs fewer services) was associated with an increase in annual outpatient visits in both counties (P = <.001 each). In Los Angeles County, having three or more peer specialist trainings (vs fewer trainings) was associated with lower use of inpatient services (P < .001). In San Diego County, having a transition age youth peer specialist and peer specialists that provide four or more services was associated with lower use of inpatient services (P < .001 each). CONCLUSIONS: Types of peer support and number of types of peer services were associated with mental health service utilization. Detailed examination of the roles of peer specialists is merited to identify the specific pathways that improve outcomes.

Advancing Integrated Care through Practice Coaching.

INTRODUCTION: Practice coaches are skilled consultants who work in health care service delivery systems to make changes designed to improve patient outcomes, yet research is limited regarding their use to support integrated health care. This article describes the use of practice coaches in a large-scale effort to implement integrated care in the United States for patients with complex care needs. THEORY AND METHODS: This immersive, qualitative project involved five implementation team members; eight practice coaches; and 77 staff members from 12 health care organizations. Semistructured interviews were recorded and transcribed verbatim. Thematic and content analyses were applied in multiple stages to understand the use of practice coaches. RESULTS: Qualitative themes about the use of practice coaching in this initiative were: (a) development of "a very rich coaching model"; (b) moving from an organic to standardized coaching approach; and (c) coaches representing the "face of the initiative." DISCUSSION: A rich coaching model that includes an interdisciplinary coaching team can support integrated care transformation but challenges including finding highly qualified coaches and sustaining and disseminating the coaching model exist. Standardization was seen as a way to address such challenges. CONCLUSION: Practice coaches can provide individualized, hands-on guidance to support successful implementation of integrated care.

Racial-Ethnic Differences in Service Use Patterns Among Young, Commercially Insured Individuals With Recent-Onset Psychosis.

OBJECTIVE: The aim of this study was to investigate racial-ethnic differences in use of mental health services and antipsychotic medication in the year following the recent onset of a psychotic disorder and to examine the role of household income as a proxy for socioeconomic status. METHODS: Deidentified administrative claims data from the OptumLabs Data Warehouse were used to identify 8,021 commercially insured individuals ages 14 through 30 with a recent-onset psychotic disorder (January 1, 2011, through December 31, 2015). The authors compared mental health service use among African-American (11.5%), Hispanic (11.0%), and non-Hispanic white (77.4%) individuals during the year following an index diagnosis and adjusted these analyses for household income. RESULTS: The probability of any use of outpatient mental health services was lower among African-American (67.4%±1.4%) and Hispanic individuals (66.5%±1.5%) compared with non-Hispanic white patients (72.3%±0.6%; p<0.05 for each comparison). Among those who used services, African-American and Hispanic individuals had fewer mean outpatient mental health visits per year compared with non-Hispanic whites (9.7±0.7 and 10.2±0.7 versus 14.3±0.5, respectively, p<0.001 for each comparison). These racial-ethnic differences in service use remained after adjustment for household income. CONCLUSIONS: Among young, commercially insured individuals using outpatient services following an index diagnosis of psychotic disorder, African Americans and Hispanics received less intensive outpatient mental health care than their non-Hispanic white counterparts. Amid the upsurge of early intervention programs, special attention should be paid to increasing access to mental health services for racial-ethnic minority groups.

Service Use Following First-Episode Schizophrenia Among Commercially Insured Youth.

OBJECTIVE: To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed. METHOD: Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis. RESULTS: In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit. CONCLUSIONS: Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES.

Rehabilitation After Total Knee Arthroplasty: Do Racial Disparities Exist?

BACKGROUND: Racial disparities in functional outcomes after total knee arthroplasty (TKA) exist. Whether differences in rehabilitation utilization contribute to these disparities remains to be investigated. METHODS: Among 8349 women enrolled in the prospective Women's Health Initiative cohort who underwent primary TKA between 2006 and 2013, rehabilitation utilization was determined through linked Medicare claims data. Postacute discharge destination (home, skilled nursing facility, and inpatient rehabilitation facility), facility length of stay, and number of home health physical therapy (HHPT) and outpatient physical therapy (OPPT) sessions were compared between racial groups. RESULTS: Non-Hispanic black women had worse physical function (median score, 65 vs 70) and higher likelihood of disability (13.2% vs 6.9%) than non-Hispanic white women before surgery. After TKA, black women were more likely to be discharged postacutely to an institutional facility (64.3% vs 54.5%) than white women, were more likely to receive HHPT services (52.6% vs 47.8%), and received more HHPT and OPPT sessions. After stratification by postacute discharge setting, the likelihood of receipt of HHPT or OPPT services was similar between racial groups. No significant difference in receipt of HHPT or OPPT services was found after use of propensity score weighting to balance health and medical characteristics indicating severity of need for physical therapy services. CONCLUSION: Rehabilitation utilization was generally comparable between black and white women who received TKA when accounting for need. There was no evidence of underutilization of post-TKA rehabilitation services, and thus disparities in post-TKA functional outcomes do not appear to be a result of inequitable receipt of rehabilitation care.

Exacerbations, Health Resource Utilization, and Costs Among Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease Treated with Nebulized Arformoterol Following a Respiratory Event.

BACKGROUND: Long-acting beta2-agonists (LABAs), with or without inhaled corticosteroids (ICSs), delivered by handheld inhalers or nebulizers are recommended as maintenance therapy in chronic obstructive pulmonary disease (COPD). This study evaluated exacerbations, health resource utilization (HRU), and costs among Medicare beneficiaries with COPD on handheld ICS+LABA who switched to nebulized arformoterol (ARF) or continued ICS+LABA following a respiratory event. METHODS: Using Medicare claims, we identified beneficiaries with COPD (international classification of disease, 9th revision, clinical modification [ICD-9-CM] 490-492.xx, 494.xx, 496.xx) between 2010-2014 who had ≥ 1 year of continuous enrollment in Parts A, B, and D; ≥ 2 COPD-related outpatient visits ≥ 30 days apart or ≥ 1 hospitalization(s); ICS+LABA use 90-days before ARF initiation; and a respiratory event (COPD-related hospitalization or emergency department [ED] visit < 30 days before ARF initiation). Using propensity scores, 423 beneficiaries who switched to ARF were matched to 423 beneficiaries who continued on handheld ICS+LABA (controls). Difference-in-difference regression models examined outcomes at 180-days follow-up. RESULTS: Beneficiaries who switched to ARF had 1.5 fewer exacerbations (p=0.015) but no difference in hospitalizations and ED visits compared to controls. Durable medical equipment (DME) costs were higher among ARF users than controls ($1590), yet total health care costs were similar due to cost offsets by ARF in pharmacy (-$794), inpatient (-$524), and outpatient care (-$65). ARF accounted for 55% ($886.63) of DME costs, with the remaining costs attributed to oxygen therapy ($428.10) and nebulized corticosteroids ($590.85). CONCLUSIONS: Switching from handheld ICS+LABA to nebulized ARF resulted in fewer COPD exacerbations among Medicare beneficiaries. Nebulized LABAs may improve outcomes in selected patients with COPD.

Medication management patterns among Medicare beneficiaries with chronic obstructive pulmonary disease who initiate nebulized arformoterol treatment.

Purpose: Global evidence-based treatment strategies for chronic obstructive pulmonary disease (COPD) recommend using long-acting bronchodilators (LABDs) as maintenance therapy. However, COPD patients are often undertreated. We examined COPD treatment patterns among Medicare beneficiaries who initiated arformoterol tartrate, a nebulized long-acting beta2 agonist (LABA), and identified the predictors of initiation. Methods: Using a 100% sample of Medicare administrative data, we identified beneficiaries with a COPD diagnosis (ICD-9 490-492.xx, 494.xx, 496.xx) between 2010 and 2014 who had ≥1 year of continuous enrollment in Parts A, B, and D, and ≥2 COPD-related outpatient visits within 30 days or ≥1 hospitalization(s). After applying inclusion/exclusion criteria, three cohorts were identified: (1) study group beneficiaries who received nebulized arformoterol (n=11,886), (2) a subset of the study group with no LABD use 90 days prior to initiating arformoterol (n=5,542), and (3) control group beneficiaries with no nebulized LABA use (n=220,429). Logistic regression was used to evaluate predictors of arformoterol initiation. Odds ratios (ORs), 95% confidence intervals (CIs), and p values were computed. Results: Among arformoterol users, 47% (n=5,542) had received no LABDs 90 days prior to initiating arformoterol. These beneficiaries were being treated with a nebulized (50%) or inhaled (37%) short-acting bronchodilator or a systemic corticosteroid (46%), and many received antibiotics (37%). Compared to controls, beneficiaries who initiated arformoterol were significantly more likely to have had an exacerbation, a COPD-related hospitalization, and a pulmonologist or respiratory therapist visit prior to initiation (all p<0.05). Beneficiaries with moderate/severe psychiatric comorbidity or dual-eligible status were significantly less likely to initiate arformoterol, as compared to controls (all p<0.05). Conclusion: Medicare beneficiaries who initiated nebulized arformoterol therapy had more exacerbations and hospitalizations than controls 90 days prior to initiation. Findings revealed inadequate use of maintenance medications, suggesting a lack of compliance with evidence-based treatment guidelines.

Predictors of Nebulized Arformoterol Treatment: A Retrospective Analysis of Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease.

This study examined sociodemographic and clinical characteristics, treatment patterns, and health resource utilization among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD) to identify predictors of nebulized arformoterol treatment. Using Medicare administrative data from 2010 to 2014, beneficiaries with ≥2 COPD outpatient visits ≥30 d apart or ≥1 COPD-related hospitalization(s) (ICD-9-CM 491.xx, 492.xx, and 496) were identified. Inclusion criteria required ≥1 COPD medication claim(s) and continuous enrollment in Parts A, B, and D. Four cohorts were identified: (a) 11,887 arformoterol users, (b) a subsample of arformoterol users (n = 1,778) who were hospitalized and discharged 30 d before initiating arformoterol, (c) 450,178 controls who had not received arformoterol, and (d) a subsample of controls (n = 21,910) who had hospitalizations. Logistic regression analysis was used to evaluate predictors of arformoterol treatment. The majority of beneficiaries were older than 70 years of age, female, Caucasian, and 47% were dual-eligible. The strongest predictors of arformoterol treatment were oxygen therapy, systemic corticosteroid or methylxanthine use, an exacerbation, a COPD-related hospitalization, and receiving care from a pulmonologist (all p < .001). Dual-eligibility, being a racial/ethnic minority, and having severe psychiatric comorbidity or immunodeficiency lowered the odds of receiving nebulized arformoterol (all p < .001). Among beneficiaries with recent hospitalizations, exacerbations and COPD-related admissions increased the odds of receiving arformoterol (p < .001). Nebulized arformoterol treatment was more likely to be initiated in sicker patients with COPD. Ensuring access to nebulized maintenance therapy is important and particularly warranted for COPD populations with greater medical needs.

Evaluation Of The Behavioral Health Integration And Complex Care Initiative In Medi-Cal.

This article reports how a large Medi-Cal managed care plan addressed challenges in accessing health care for approximately 7,000 enrollees with multiple chronic conditions through a project known as the Behavioral Health Integration and Complex Care Initiative. The initiative increased staffing for care management, care coordination, and behavioral health integration. In our evaluation of the initiative, we demonstrated that participation in it was associated with improved clinical indicators for common chronic conditions, reduced inpatient costs in some sites, and improved patient experience in all sites. The initiative may be best understood as a new type of ongoing strategic partnership among the health plan, its providers, and their patients. Changes in funding to support models of value-based care are needed to sustain these efforts in the long term.

Integrated Primary Care in Assertive Community Treatment.

Assertive community treatment (ACT) has the potential to serve as a medical home for adults with serious mental illness, a population that experiences some of the most significant health disparities in the United States. Using site visit methodology, the authors describe partnerships that were created between five ACT programs and federally qualified health centers (FQHCs) to provide integrated behavioral health and primary care. The authors examined rates of screening for common chronic conditions. The programs used three distinct approaches: two programs colocated ACT teams at an FQHC, two programs employed primary care providers who split their time between the FQHC and the ACT program, and one program embedded a primary care provider within the ACT team. Effective communication between staffs may be more important than type of partnership in determining integration success.

Implementation of Integrated Health Homes and Health Outcomes for Persons With Serious Mental Illness in Los Angeles County.

OBJECTIVE: The Medicaid health home option of the Affordable Care Act provides a new opportunity to address the fragmented system of care for persons with serious mental illness. This study examined the implementation of integrated health homes in Los Angeles County. METHODS: Longitudinal data on client-reported physical health status, clinician-reported mental health recovery, and screening for common chronic conditions among 1,941 persons enrolled in integrated care programs for serious mental illness and chronic general medical illness were combined with site visit data measuring the level of integration of general medical and mental health care among ten integrated care programs. Various analyses were used to compare outcomes by level of program integration (generalized estimating equations for physical health status and mental health recovery and logistic regression and chi-square tests for screening for common chronic conditions and clinical risk factors). RESULTS: Clients in more highly integrated programs had greater improvements in physical health status and mental health recovery and higher rates of screening for common chronic conditions compared with clients in less integrated programs. They also had greater reductions in hypertension but a worrisome increase in prediabetes and diabetes. CONCLUSIONS: Highly integrated mental health and general medical programs were associated with greater improvements in health outcomes compared with less integrated programs. Additional research is necessary to identify predictors of integration, to determine which aspects of integration drive improvements in health outcomes, and to identify strategies to increase integration within less integrated programs. Efforts are needed to coordinate pharmacotherapy, including increased consideration of the metabolic effects of antipsychotic medication.

Implementation of Age-Specific Services for Transition-Age Youths in California.

OBJECTIVES: This study examined the implementation of age-specific services for transition-age youths in California under the Mental Health Services Act (MHSA). METHODS: This study employed a sequential, exploratory mixed-methods design. Qualitative interviews with 39 mental health service area administrators in California were analyzed to develop an understanding of how the MHSA has facilitated the development of youth-specific programs or services. A quantitative survey of 180 youth-focused programs was also used to describe the range of services that were implemented, the use of evidence-based and promising practices, and the role of youths in the design, planning, delivery, and evaluation of services. RESULTS: Administrators described the MHSA as providing a programmatic focus and financial support for youth-specific services, outlining a stakeholder process to create buy-in and develop a vision for services, and emphasizing the role of youths in service delivery and planning. Youth-specific programs implemented a diverse array of services, including general medical care; employment and education support; housing placement and support; and family, mentoring, and social support. Programs described implementing evidence-based and promising practices and involving youths in service planning, implementation, or quality improvement activities. CONCLUSIONS: The MHSA has had a substantial impact on the landscape of youth-specific services in California by expanding both the number of programs and the diversity in types of services and by promoting the engagement of youths in the planning and delivery of services. Additional efforts are necessary to determine the extent to which youth-specific services yield greater improvements in youths' outcomes compared with services designed for adults.