Effect of Providing Evidence-Based Mental Health Treatment on Retention in Care Among Medicaid-Enrolled Youths.

OBJECTIVE: Youths who start behavioral health treatment often stop before completing a therapeutic course of care. To increase treatment engagement and quality of care, the Evidence-Based Practice and Innovation Center in Philadelphia has incentivized use of evidence-based practices (EBPs) for mental health care of youths. The authors aimed to compare treatment outcomes between youths who received EBP care and those who did not. METHODS: Using EBP-specific billing codes and propensity score matching, the authors compared treatment retention among youths who received trauma-focused cognitive-behavioral therapy (TF-CBT; N=413) or parent-child interaction therapy (PCIT; N=90) relative to matched samples of youths in standard outpatient therapy (N=503). RESULTS: Youths with a minimum of one session of TF-CBT or PCIT attended a second session at higher rates than did youths in the matched control group (TF-CBT: 96% vs. 68%, p<0.01; PCIT: 94% vs. 69%, respectively, p<0.01). On average, these returning youths attended more sessions in the EBP groups than in the control group (TF-CBT: 15.9 vs. 11.5 sessions, p<0.01; PCIT: 11.2 vs. 6.9 sessions, p<0.01). CONCLUSIONS: These findings indicate that, in addition to improving quality of care, EBP implementation helps address the major challenge that most youths who engage with treatment are not retained long enough for care to have therapeutic effects. Future research should examine the mechanisms through which EBPs can improve treatment retention.

A multi-constituent qualitative examination of facilitators and barriers to caregiver coaching for autistic children in publicly funded early intervention.

LAY ABSTRACT: Caregiver coaching is an evidence-based practice for young autistic children, but it is not widely used in community-based early intervention services. Previous research has explored why caregiver coaching is not widespread in early intervention, but only from the perspective of early intervention providers. Caregivers, providers, and administrators are all involved in the decision of whether to use caregiver coaching in early intervention. Therefore, it is important to include all perspectives in research regarding this practice. In this study we interviewed 20 caregivers of autistic children, 36 early intervention providers, and 6 administrators from early intervention agencies and asked questions about their perspectives regarding the use of caregiver coaching in early intervention. We did this to figure out what factors help and hinder the use of caregiver coaching in this setting and to see how caregivers, providers, and administrators agreed or disagreed on these factors. All participants agreed that caregivers' attitudes and expectations can influence whether caregiver coaching is used. In addition, all participants agreed that when caregivers and providers collaborate and have a strong working relationship, it can facilitate the use of caregiver coaching in early intervention. Other factors, such as caregiver stress and provider flexibility were also discussed. Based on these findings, we suggest strategies that can be used to possibly increase the use of caregiver coaching in early intervention for autistic children and their families.

Utilization of Reimbursed Acupuncture Therapy for Low Back Pain.

Importance: Treating low back pain (LBP) often involves a combination of pharmacologic, nonpharmacologic, and interventional treatments; one approach is acupuncture therapy, which is safe, effective, and cost-effective. How acupuncture is used within pain care regimens for LBP has not been widely studied. Objective: To document trends in reimbursed acupuncture between 2010 and 2019 among a large sample of patients with LBP, focusing on demographic, socioeconomic, and clinical characteristics associated with acupuncture use and the nonpharmacologic, pharmacologic, and interventional treatments used by patients who utilize acupuncture. Design, Setting, and Participants: This cross-sectional study included insurance claims of US adults in a deidentified database. The study sample included patients diagnosed with LBP between 2010 and 2019. Data were analyzed between September 2023 and June 2024. Main Outcomes and Measures: Changes in rates of reimbursed acupuncture utilization between 2010 and 2019, including electroacupuncture use, which involves the electrical stimulation of acupuncture needles. Covariates included age, sex, race and ethnicity, income, educational attainment, region, and a chronic LBP indicator. Secondary analyses tracked other nonpharmacologic treatments (eg, physical therapy, chiropractic care), pharmacologic treatments (eg, opioids, gabapentinoids), and interventional treatments (eg, epidural steroid injections). Results: The total sample included 6 840 497 adults with LBP (mean [SD] age, 54.6 [17.8] years; 3 916 766 female [57.3%]; 802 579 Hispanic [11.7%], 258 087 non-Hispanic Asian [3.8%], 804 975 non-Hispanic Black [11.8%], 4 974 856 non-Hispanic White [72.7%]). Overall, 106 485 (1.6%) had 1 or more acupuncture claim, while 61 503 (0.9%) had 1 or more electroacupuncture claim. The rate of acupuncture utilization increased consistently, from 0.9% in 2010 to 1.6% in 2019; electroacupuncture rates were relatively stable. Patients who were female (male: odds ratio [OR], 0.68; 99% CI, 0.67-0.70), Asian (OR, 3.26; 99% CI, 3.18-3.35), residing in the Pacific region (New England: OR, 0.26; 99% CI, 0.25-0.28), earning incomes of over $100 000 (incomes less than $40 000: OR, 0.59; 99% CI, 0.57-0.61), college educated (high school or less: OR, 0.32; 99% CI, 0.27-0.35), and with chronic LBP (OR, 2.39; 99% CI, 2.35-2.43) were more likely to utilize acupuncture. Acupuncture users were more likely to engage in other nonpharmacologic pain care like physical therapy (39.2%; 99% CI, 38.9%-39.5% vs 29.3%; 99% CI, 29.3%-29.3%) and less likely to utilize prescription drugs, including opioids (41.4%; 99% CI, 41.1%-41.8% vs 52.5%; 99% CI, 52.4%-52.5%), compared with nonusers. Conclusions and Relevance: In this cross-sectional study, we found that acupuncture utilization among patients with LBP was rare but increased over time. Demographic, socioeconomic, and clinical characteristics were associated with acupuncture utilization, and acupuncture users were more likely to utilize other nonpharmacologic treatments and less likely to utilize pharmacologic treatments.

Trapped in Violence: A Life Table Analysis of Firearm Injury and Death Among Adolescent Black Males.

PURPOSE: We report the chances of 14-year-old males becoming victims of firearm injury or death before age 25 in Philadelphia, Pennsylvania. METHODS: Using life table methods, we followed 4,501 Black males aged 14 years, and a comparison group of 1,751 White males, over 11 years. RESULTS: Among 14-year-old Black males, the risk of a nonfatal firearm injury before age 25 was 10.1% (95% confidence interval, 9.2%-11.0%), the risk of death from firearms was 2.5% (1.7%-3.2%), and the combined risk was 12.5% (11.0%-14.1%). Among White males, the risk of nonfatal firearm injury was 0.8% (0.3%-1.2%), the risk of death was 0.3% (0.02%-0.5%), and the combined risk was 1.0% (0.5%-1.5%). DISCUSSION: Risk estimates reveal the dire likelihood of firearm injury or death among Black adolescent males in Philadelphia. Immediate interventions are needed to de-escalate conflicts, provide supports, and address the upstream causes of violence like poverty and structural racism.

A cohort study of engagement in telehealth psychotherapy versus in-person services.

OBJECTIVE: Although telehealth psychotherapies have been studied for over 20 years, mental health services remained largely delivered in person until the COVID-19 pandemic forced clinics to reconsider the utility of telehealth psychotherapy. This study aims to compare patient engagement in in-person versus telehealth services in outpatient psychotherapy for mood and anxiety disorders. METHOD: A cohort investigation was conducted, using a propensity score matched sample, extracted from an electronic health record (EHR) to compare engagement in psychotherapy for 762 patients who used in-person services before the pandemic to a cohort of 762 patients who used telehealth psychotherapy after the onset of COVID-19. The authors compared cohorts on initial engagement in psychotherapy services following an initial intake, number of psychotherapy sessions attended, and the rate of missed sessions. RESULTS: There was a 26% increase in the total number of individual psychotherapy sessions attended when the clinics transitioned to telehealth services (p < .001). In addition, patients who received telehealth psychotherapy were five times more likely to not cancel or miss any scheduled sessions (p < .001). CONCLUSION: These results indicate that telehealth services may result in improved treatment engagement for outpatient centers focused on brief evidence-based psychotherapies for mood and anxiety disorders.

Building Better Bridges: Outcomes of a Community-Partnered New School Transition Intervention for Students on the Autism Spectrum.

New school transitions can be challenging for students on the autism spectrum. No published, evidence-based interventions exist to support families and teachers of students transitioning to elementary and secondary school during this critical period. Using Community Partnered Participatory Research, we developed Building Better Bridges (BBB), a caregiver coaching intervention that includes training on effective school communication, educational rights, advocacy, and child preparation strategies. We compared BBB (n = 83) to a module/resources-only comparison (n = 87) in a four-site randomized controlled trial in racially and ethnically diverse, under-resourced communities. In our intent-to-treat analysis, caregivers and teachers in BBB rated students' transitions to the new classroom as more positive, relative to the comparison group. Results suggest this low-cost intervention can improve the transition process for families and students at high risk of poor transitions.

Lessons Learned from Remote Assessment of Mother-Infant Interactions Among Women with Postpartum Depression.

Purpose: The COVID-19 pandemic posed challenges to measuring mother-infant interactions, a critical outcome for many interventions to support mothers with postpartum depression symptoms and their new infants. The current study describes the process and lessons learned from implementing a remote assessment of mother-infant interactions during the pandemic. Description: At the onset of the COVID-19 pandemic, we pivoted from in-person to using two different strategies to remotely assess mother-infant interactions: (1) participants independently recorded and uploaded videos of free-play with their child; and (2) research team conducted a live-video recording of the free-play. Assessment: We found initial barriers including technical and video quality issues but overall, a remote option could increase enrollment and retention rates in a sample of postpartum women across various racial/ethnic groups and economic levels. Conclusion: Our experiences in conducting remote assessments with postpartum women add to growing evidence for the feasibility and validity of remote visits. This showed how our methods can be implemented in future research and in practice with postpartum mothers and their infants.

Exploring Teachers' Intentions to Use Behavioral Classroom Interventions.

Multi-tiered systems of behavioral supports offer teachers tools to implement positive, antecedent- or consequence-based interventions for all students (i.e., Tier 1), and for those who need additional support (i.e., Tier 2), such as students with ADHD. Because these interventions may be challenging to use, targeted, theory-driven implementation strategies may assist teachers in implementing them with fidelity. This exploratory study examined teachers' intended and self-reported use of specific Tier 1 and Tier 2 behavioral classroom interventions. Sixty-five K-8 teachers from five urban public schools completed an online survey about their intentions to use and self-reported use of four Tier 1 and Tier 2 behavioral classroom interventions. Teachers' intentions varied by intervention, with the weakest intentions for using a daily behavior report (Tier 2), and weaker intentions for using high rates of specific praise than for other Tier 1 interventions. Teacher's self-reported use was significantly lower than intended use for Tier 1 interventions, but not Tier 2 interventions. Results were generally similar whether the referent group was students with ADHD symptoms or the entire class. These results suggest specific factors to target to support teachers' use of behavioral classroom interventions.

Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol.

BACKGROUND: The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth. METHOD: This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys. CONCLUSION: If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.

Helping Practitioners Stop, Drop, and Roll: Suggestions to Help Improve Responses to Intense Clinical Events.

Community practitioners inconsistently implement evidence-based interventions. Implementation science emphasizes the importance of some practitioner characteristics, such as motivation, but factors such as practitioners' emotion regulation and cognitive processing receive less attention. Practitioners often operate in stressful environments that differ from those in which they received training. They may underestimate the impact of their emotional state on their ability to deliver evidence-based interventions. This "hot-cold state empathy gap" is not well studied in mental health care. In this Open Forum, the authors describe scenarios where this gap is affecting practitioners' ability to implement evidence-based practices. The authors provide suggestions to help practitioners plan for stressful situations.

A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention.

BACKGROUND: Most psycho-social interventions contain multiple components. Practitioners often vary in their implementation of different intervention components. Caregiver coaching is a multicomponent intervention for young autistic children that is highly effective but poorly implemented in community-based early intervention (EI). Previous research has shown that EI providers' intentions, and the determinants of their intentions, to implement caregiver coaching vary across components. Organizational culture and climate likely influence these psychological determinants of intention by affecting beliefs that underlie attitudes, norms, and self-efficacy to implement an intervention. Research in this area is limited, which limits the development of theoretically driven, multilevel implementation strategies to support multi-component interventions. This mixed methods study evaluated the relationships among organizational leadership, culture and climate, attitudes, norms, self-efficacy, and EI providers' intentions to implement the components of caregiver coaching. METHODS: We surveyed 264 EI providers from 37 agencies regarding their intentions and determinants of intentions to use caregiver coaching. We also asked questions about the organizational culture, climate, and leadership in their agencies related to caregiver coaching. We used multilevel structural equation models to estimate associations among intentions, psychological determinants of intentions (attitudes, descriptive norms, injunctive norms, and self-efficacy), and organizational factors (implementation climate and leadership). We conducted qualitative interviews with 36 providers, stratified by strength of intentions to use coaching. We used mixed-methods analysis to gain an in-depth understanding of the organization and individual-level factors. RESULTS: The associations among intentions, psychological determinants of intentions, and organizational factors varied across core components of caregiver coaching. Qualitative interviews elucidated how providers describe the importance of each component. For example, providers' attitudes toward coaching caregivers and their perceptions of caregivers' expectations for service were particularly salient themes related to their use of caregiver coaching. CONCLUSION: Results highlight the importance of multi-level strategies that strategically target individual intervention components as well as organization-level and individual-level constructs. This approach holds promise for improving the implementation of complex, multicomponent, psychosocial interventions in community-based service systems.

Reaching "The Other Half": Teacher Referral Increases Inclusivity in Intervention Research for Neurodivergent School-Age Children.

OBJECTIVE: Researchers employed two recruitment strategies in a school-based comparative effectiveness trial for students with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) or autism. This study assessed the: 1) effectiveness of school-based referrals for identifying students meeting diagnostic criteria and 2) impact of eliminating requirements for existing diagnoses on recruitment, sample characteristics, and intervention response. METHOD: Autistic students and students with ADHD in schools serving underresourced communities were recruited for an executive functioning (EF) intervention trial over 2 years. In Year 1, school staff nominated students with previous diagnoses. In Year 2, school staff nominated students demonstrating EF challenges associated with ADHD or autism; previous diagnosis was not required. Study staff then confirmed diagnoses. RESULTS: More students were included in Year 2 (N = 106) than Year 1 (N = 37). In Year 2, 96% of students referred by school staff met diagnostic criteria for ADHD or autism, 53% of whom were not previously diagnosed. Newly identified students were less likely than previously diagnosed students to be receiving services and, for those with ADHD, were more likely to speak primarily Spanish at home. Previously diagnosed and newly identified students did not differ on other demographic variables or intervention response. Caregivers of previously diagnosed students reported more symptoms than caregivers of newly identified students for both diagnostic groups. Previously diagnosed students with ADHD had more researcher-rated symptoms than newly identified students. CONCLUSIONS: Recruitment for an intervention study using behavior-based referrals from school staff enhanced enrollment without compromising the sample's diagnostic integrity and engaged children who otherwise would have been excluded.

Short report on navigating access to care for Medicaid-enrolled autistic youth and young adults: Examining accrual of intellectual disability diagnoses in adolescence.

LAY ABSTRACT: What is known? In most states, Medicaid waivers provide individuals with an intellectual disability diagnosis generous healthcare coverage throughout adulthood. By comparison, fewer Medicaid programs are available for autistic individuals, and they are more likely to experience disruptions, or gaps, in Medicaid coverage and subsequently not re-enroll.What this paper adds? One in five autistic individuals with Medicaid coverage between ages 8 and 25 accrued a new intellectual disability diagnosis. The probability of a new intellectual disability diagnosis was higher among those who had previous disruptions in Medicaid coverage.Implications for research and policy. Expanding Medicaid to cover autistic people of all ages could decrease the need for intellectual disability diagnosis accrual. Input from autistic individuals and their families regarding their health insurance access and healthcare experiences is critically important to understanding next steps for research.

Opportunities to improve opioid use disorder care for hospitalised patients with endocarditis.

BACKGROUND: Driven by increased injection opioid use, rates of hospitalisation for infective endocarditis, an infection associated with injection drug use, are increasing. In the USA, 1 in 10 hospitalised patients for opioid use disorder-associated infective endocarditis (OUD-IE) die in the hospital and 1 in 20 have a patient-directed discharge. Emerging models of care reveal opportunities for healthcare systems to meet the complex care needs of these patients. We characterised promising practices of staff who care for these patients and identified areas for improvement. METHODS: We conducted a qualitative study with 1-hour semistructured virtual interviews between October 2021 and March 2022. Participants included 26 healthcare staff who care for patients with OUD-IE at the Hospital of the University of Pennsylvania. We used thematic analysis of interviews guided by an abductive approach. Interviews were digitally recorded and transcribed and analysed using NVivo software. RESULTS: Interviews were characterised by three major themes: (1) care rooted in interdisciplinary collaboration; (2) managing OUD and its sequelae in a setting not designed to treat OUD; and (3) clinician needs and barriers to change. CONCLUSIONS: These findings highlight the facilitators of high-quality treatment for patients with OUD-IE, as well as the key areas for improvement. Findings add context to the complexity that both the healthcare staff and patients navigate during and following hospitalisation for OUD-IE. Needed changes include training staff to talk with patients about preparing for a return to drug use following hospitalisation, and changing discharge facilities' practices that hinder access for patients with OUD-IE.

Mobile service delivery in response to the opioid epidemic in Philadelphia.

BACKGROUND: The harms of opioid use disorder (OUD) and HIV infection disproportionately impact marginalized populations, especially people experiencing homelessness and people who inject drugs (PWID). Mobile OUD service delivery models are emerging to increase access and reduce barriers to OUD care. While there is growing interest in these models, there is limited research about the services they provide, how they operate, and what barriers they face. We characterize the capacity, barriers, and sustainment of mobile OUD care services in a large city with a high incidence of OUD and HIV. METHODS: From May to August 2022, we conducted semi-structured interviews with leadership from all seven mobile OUD care units (MOCU) providing a medication for OUD or other substance use disorder services in Philadelphia. We surveyed leaders about their unit's services, staffing, operating location, funding sources, and linkages to care. Leaders were asked to describe their clinical approach, treatment process, and the barriers and facilitators to their operations. Interview recordings were coded using rapid qualitative analysis. RESULTS: MOCUs are run by small, multidisciplinary teams, typically composed of a clinician, one or two case managers, and a peer recovery specialist or outreach worker. MOCUs provide a range of services, including medications for OUD, wound care, medical services, case management, and screening for infectious diseases. No units provide methadone, but all units provide naloxone, six write prescriptions for buprenorphine, and one unit dispenses buprenorphine. The most frequently reported barriers include practical challenges of working on a MOCU (e.g. lack of space, safety), lack of community support, and patients with substantial medical and psychosocial needs. Interviewees reported concerns about funding and specifically as it relates to providing their staff with adequate pay. The most frequently reported facilitators include positive relationships with the community, collaboration with other entities (e.g. local nonprofits, the police department, universities), and having non-clinical staff (e.g. outreach workers, peer recovery specialists) on the unit. CONCLUSIONS: MOCUs provide life-saving services and engage marginalized individuals with OUD. These findings highlight the challenges and complexities of caring for PWID and demonstrate a need to strengthen collaborations between MOCU providers and the treatment system. Policymakers should consider programmatic funding for permanent mobile OUD care services.

An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER).

BACKGROUND: Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation. METHODS: We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews). DISCUSSION: Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes. TRIAL REGISTRATION: Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.

Asset Protection for Dermatologists: An Overview on Shielding Wealth from Potential Liability.

The reality of dermatology practice in the 21st century includes the potential for lawsuits and liability. While medical malpractice may be top-of-mind, there are a host of liability risks beyond malpractice-from employee claims and fiduciary liability for the practice retirement plan to premises liability and HIPAA violations-as well as potential personal liability for rental properties, car accidents (for self and children), outside businesses, personal guarantees and more. This article outlines the leading tools dermatologists can utilize to better shield their assets from potential liability-including exempt assets, co-ownership forms, and legal tools, such as limited liability companies and trusts.

Parent Coaching in Early Intervention for Autism Spectrum Disorder: A Brief Report.

Coaching caregivers of young children on the autism spectrum is a critical component of parent-mediated interventions. Little information is available about how providers implement parent coaching for children on the autism spectrum in publicly funded early intervention systems. This study evaluated providers' use of parent coaching in an early intervention system. Twenty-five early intervention sessions were coded for fidelity to established caregiver coaching techniques. We found low use of coaching techniques overall, with significant variability in use of coaching across providers. When providers did coach caregivers, they used only a few coaching strategies (e.g., collaboration and in-vivo feedback). Results indicate that targeted training and implementation strategies focused on individual coaching components, instead of coaching more broadly, may be needed to improve the use of individual coaching strategies. A focus on strengthening the use of collaboration and in-vivo feedback may be key to improving coaching fidelity overall.