Impacts of an Integrated Medicaid Managed Care Program for Adults with Behavioral Health Conditions: The Experience of Illinois.

This study assessed the impact of the Integrated Care Program (ICP), a new Medicaid managed care model in Illinois, on health services utilization and costs for adults with behavioral health conditions. Data sources included Medicaid claims, encounter records, and state payment data for 28,127 persons with a behavioral health diagnosis. Difference-in-differences models, in conjunction with propensity score weighting, were used to compare utilization and costs between ICP enrollees and a fee-for-service (FFS) comparison group. The model considered the impact of the SMART Act, which restricted access to care for the comparison group. Before the SMART Act, ICP was associated with 2.8 fewer all-cause primary care visits, 34.6 fewer behavioral health-specific outpatient visits, and 2.5 fewer all-cause inpatient admissions per 100 persons per month, and $228 lower total costs per member per month relative to the FFS group. After the SMART Act, ICP enrollees had increased outpatient and dental services utilization without significantly higher costs. The relative increase in utilization was due primarily to decreased utilization in the restricted FFS group after the SMART Act. By the end of the study period, the ICP group had 13.3 more all-cause primary care visits, 1.5 more emergency department visits, and 1.4 more dental visits per 100 persons per month relative to the FFS program. A fully-capitated, integrated managed care program has the potential to reduce overall Medicaid costs for people with behavioral health conditions without negative effects on service utilization.

Analysis of Time in Rehabilitation and Incidence of Successful Rehabilitation Within Individuals with Disabilities Receiving Occupational/Vocational Training.

Objective To investigate the incidence of successful rehabilitation, defined as 90 successive days in employment, within individuals with disabilities receiving occupational/vocational training (OVT) service. Method The follow-up records between January 1, 2004 and December 31, 2012 of 5313 individuals aged 15-55 who obtained OVT in the vocational rehabilitation (VR) program of the State of Illinois were examined. Cox regression models were used to analyze the effect of study factors on VR outcomes. Results After controlling for the other factors, males (incidence ratio [IR] 1.11, 95% CI 1.03-1.20), individuals with learning disability (IR 1.14, 95% CI 1.03-1.26), had existing employment (IR 1.40, 95% CI 1.26-1.56), and persons who were referred from educational institutions (IR 1.17, 95% CI 1.01-1.36) or community agencies (IR 1.30, 95% CI 1.14-1.48) appeared to have a relatively high incidence of successful rehabilitation. In contrast, those who lived in densely populated areas (IR ranged from 0.56 to 0.89), had physical disability (IR 0.77, 95% CI 0.68-0.88), had disability of most significant degree (IR 0.85, 95% CI 0.79-0.93), and persons with Supplemental Security Income/Social Security Disability Insurance supports (IR 0.84, 95% CI 0.76-0.94), tended to have a lower incidence of rehabilitation than their counterparts. Conclusion The incidence of successful rehabilitation seems to be related to the demographic, disability, and pre-service characteristics, but not necessarily the provider factors.

Prospective comparison of two models of integrating early infant male circumcision with maternal child health services in Kenya: The Mtoto Msafi Mbili Study.

As countries scale up adult voluntary medical male circumcision (VMMC) for HIV prevention, they are looking ahead to long term sustainable strategies, including introduction of early infant male circumcision (EIMC). To address the lack of evidence regarding introduction of EIMC services in sub-Saharan African settings, we conducted a simultaneous, prospective comparison of two models of EIMC service delivery in Homa Bay County, Kenya. In one division a standard delivery package (SDP) was introduced and included health facility-based provision of EIMC services with community engagement for client referral versus in a different division a standard package plus (SDPplus) that included community-delivered EIMC services. Babies 1-60 days old were eligible for EIMC. A representative sample of mothers and fathers of baby boys at 16 health facilities was surveyed. We examined differences between mothers and fathers in the SDP and SDPplus divisions and identified factors associated with EIMC uptake. We report adjusted prevalence ratios (aPR). Of 1660 mothers interviewed, 1501 (89%) gave approval to contact the father, and 1259 fathers (84%) were interviewed. The proportion of babies circumcised was slightly greater in the SDPplus division than the SDP division (27.3% vs 23.7%), but the difference was not significant (p = 0.08). In adjusted analyses, however, the prevalence of babies being circumcised was greater in the SDPplus division (aPR = 1.23, 95% CI:1.04-1.45) and the factors associated with a baby being circumcised were the mother having received information about EIMC (during pregnancy, aPR = 4.81, 95% CI: 2.21-3.42), having discussed circumcision with the father if married or cohabiting (aPR = 5.39, 95% CI: 3.31-8.80) or being single (aPR = 5.67, 95% CI: 3.31-9.69), perceiving herself to be living with HIV (aPR = 1.39, 95% CI: 1.15-1.67), or having a post-secondary education (aPR = 1.33, 95% CI: 1.04-1.69), and the father being Muslim (aPR = 1.85, 95% CI: 1.29-2.65) or circumcised (aPR = 1.34, 95% CI: 1.13-1.59). The median age of 2117 babies circumcised was 8 days (IQR: 1-36), and the median weight was 3.6 kg (IQR: 3.2-4.4). There were 6 moderate adverse events (AEs) (0.28%); 5 severe AEs (0.24%), all involving an injury to the glans penis, requiring hospitalization and corrective surgery; and one death probably related to the procedure. There were no AEs among the 365 procedures performed outside health facilities. Information and education campaigns must reach members of the general population, especially men and fathers, who are influential to the EIMC decision. Serious AEs using the Mogen clamp are rare, but do occur and require efficient, reliable emergency back-up. Our results can assist countries considering scale-up of EIMC services for HIV prevention as their adult VMMC programs mature.

Toward a successful vocational rehabilitation in adults with disabilities: Does residential arrangement matter?

The objective of this study was to assess whether successful vocational rehabilitation (that is, obtaining employment) among people with disabilities was affected by residential arrangement. Five groups of residential placement were considered: individuals living in a private residence, community or group residential, correctional and rehabilitation facilities, nursing home/mental health facilities, and homeless/shelter/other type of residential arrangement. The study involved a total of 46,570 vocational rehabilitation consumers aged 18 to 65 at referral in a Midwestern state. Statistical modeling was performed using quasibinomial logistic regression. It was found that compared to individuals living in private residences, those in correctional or rehabilitation facilities were at increased odds of successful rehabilitation, whereas those living in homeless/shelter/other residential arrangement and those living in nursing homes/mental health facilities were in significantly decreased odds of being rehabilitated. Individuals living in community or group residential, however, had no statistical difference in vocational rehabilitation outcomes compared to individuals living in private residences. The implications for rehabilitation research and practice are discussed.

Vocational Rehabilitation of Transition-Age Youth with Disabilities: A Propensity-Score Matched Study.

Objective To investigate the employment outcomes of vocational rehabilitation (VR) services for youth with disabilities in a targeted, enhanced, and contract-based secondary transition program as compared to the traditional VR transition services. Methods A population-based study was conducted on 4422 youth with physical, intellectual, learning, mental and hearing disabilities aged 14-21 at application and whose case was closed after receiving VR transition services in a Midwestern state. Selected youth were classified into either targeted secondary transition program (START) or non-START treatment group. The employment outcomes of the groups were compared using propensity-score matching procedures. Results 2211 youth with disabilities in each treatment group were successfully matched based on demographic characteristics, types of disabilities, existence of severe functional limitations, and year of referral. The overall rehabilitation rate was 57 % [95 % confidence interval (CI) 56-59 %], where the START group rate was 61 % (95 % CI 59-63 %) and the non-START group 53 % (95 % CI 51-55 %). The propensity-score matched odds ratio (OR) was 1.40 (95 % CI 1.24-1.58; p < 0.001). Subgroup analyses showed that the odds of rehabilitation in youth with disabilities were consistently higher when they were in START as compared to non-START (OR ranged from 1.27 to 1.92 with p < 0.05 except for the Hispanic subgroup). Conclusion The results suggest that VR services in a targeted, enhanced, and contract-based secondary transition program are more effective in transitioning youth with disabilities to employment than the regular VR transition services.

Risk factors for failure to enter vocational rehabilitation services among individuals with disabilities.

PURPOSE: To investigate the risk factors for failure of individuals with disabilities to enter the vocational rehabilitation (VR) programme, including the cases where they had been formally accepted but were yet to receive any service. METHODS: We used prospective cohort data from a Midwestern US state, and analysed 126,251 and 94,517 individuals, respectively, for acceptance and admission into VR services. Statistical analysis was conducted using Poisson regression models with robust variance estimator. RESULTS: Individuals with blind/visual disability, had prior history of employment, and who received public support tended to have lower risks of non-acceptance and non-admission. Being non-White, at higher education, ever/currently married, and with physical/orthopaedic disability appeared to increase the risks of both outcomes. The adjusted relative risk of non-acceptance was 0.58 (95% confidence interval: 0.52, 0.64) if the individuals had 4 or more functional limitations as compared with those with fewer limitations. This factor was not significant for VR admission. CONCLUSION: Disability factors, demographic determinants, and certain miscellaneous characteristics were associated with the risks of non-acceptance and non-admission into VR. Implications for Rehabilitation Individuals with disabilities are more likely to be unemployed than the population without disabilities, and they are thus more prone to adverse health effects of unemployment. Vocational rehabilitation (VR) is a proven intervention to improve employment outcomes among individuals with disabilities. Our study indicates that the complexity of the selection process for entering VR and various factors beyond disability may prevent individuals to benefit from the VR programme. Rehabilitation programme authorities need to monitor and simplify the selection process into VR services and, together with rehabilitation practitioners, promote a selection process that pays careful attention on the factors that are related to individual risk of failure for entering VR.