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.

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.

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.

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.

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.

A Continuum-Based Framework as a Practice Assessment Tool for Integration of General Health in Behavioral Health Care.

OBJECTIVE: General medical conditions among patients with mental and substance use disorders are often not adequately detected and managed in behavioral health settings. The project described in this study sought to investigate how behavioral health clinics used a new general health integration (GHI) framework to assess integration efforts. METHODS: Eleven community behavioral health clinics were introduced to a new continuum-based framework for use in GHI assessment. A multidisciplinary team in each clinic was tasked with identifying current GHI interventions according to several framework stages (preliminary, intermediate 1, intermediate 2, and advanced) among eight domains and 15 related subdomains. The clinics provided feedback on the framework's utility for GHI planning and advancement. RESULTS: The clinics could readily identify distinct integration interventions within each domain and subdomain. Clinics reported strengths in the domains of trauma-informed care, self-management support, social service linkages, and quality improvement. Opportunities for future advancement in integration of general health services were identified in the major domains of screening and referral, evidence-based treatments, care teams, and sustainability. The clinics also described potential benefits of the framework to further advance and implement GHI best practices. CONCLUSIONS: The clinics could use the framework as a practice assessment of integration efforts with minimal guidance and identify several evidence-based integration interventions. Some GHI interventions were seen as strengths and as opportunities for further advancement. Longitudinal evaluation among a larger number of and more geographically diverse behavioral health clinics seeking to advance their GHI practices will improve the GHI framework's generalizability and potential for dissemination.

Implementation of Behavioral Health Integration in Small Primary Care Settings: Lessons Learned and Future Directions.

Primary care practices are in great need of practical guidance on the steps they can take to build behavioral health integration (BHI) capacities, particularly for smaller practice settings with fewer resources. 11 small primary care sites (≤ 5 providers) throughout New York State utilized a continuum framework of core components of BHI in combination with technical assistance. Surveys were collected at baseline, 6-months, and 12-months. Semi-structured interviews and focus groups were conducted during site visits, and a stakeholder roundtable was facilitated to address broader themes. Data were analyzed using qualitative thematic analysis. Practices reported successful engagement with the framework and actively participated in planning and advancing BHI operations. Greater success was observed in practices with existing on-site BHI services, identified champions for BHI, early and sustained training and involvement of providers and administrators, use of collaborative agreements with external behavioral health providers, and capacity to successfully receive reimbursements for BHI services. Advancing health information technologies was a challenge across sites. Financing and policy factors were viewed as critically important to advance integration efforts. The pilot of a continuum framework offers lessons for primary care practices and policymakers to advance integrated BH care.

Primary and Behavioral Health Care Integration Program: Impacts on Health Care Utilization, Cost, and Quality.

This article describes an extension of the RAND Corporation's evaluation of the Substance Abuse and Mental Health Services Administration's Primary and Behavioral Health Care Integration (PBHCI) grants program. PBHCI grants are designed to improve the overall wellness and physical health status of people with serious mental illness or co-occurring substance use disorders by supporting the integration of primary care and preventive PH services into community behavioral health centers where individuals already receive care. From 2010 to 2013, RAND conducted a program evaluation of PBHCI, describing the structure, process, and outcomes for the first three cohorts of grantee programs (awarded in 2009 and 2010). The current study extends previous work by investigating the impact of PBHCI on consumers' health care utilization, total costs of care to Medicaid, and quality of care in three states. The evidence suggests that PBHCI was successful in reducing frequent use of emergency room and inpatient services for physical health conditions, reducing costs of care, and improving follow-up after hospitalization for a mental illness. However, PBHCI evidence does not suggest that PBHCI had a consistent effect on quality of preventive care and health monitoring for chronic physical conditions. These findings can guide the design of future cohorts of PBHCI clinics to build on the strengths with respect to shifting emergency department and inpatient care to less costly and more effective settings and address the continuing challenge of integrating care between specialty behavioral health providers and general medical care providers.

Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector.

People with serious mental illness die 10-20 years earlier, compared with the overall population, and the excess mortality is driven by undertreated physical health conditions. In the United States, there is growing interest in models integrating physical health care delivery, management, or coordination into specialty mental health programs, sometimes called "reverse integration." In November 2019, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness convened a forum of 25 experts to discuss the current state of the evidence on integrated care models based in the specialty mental health system and to identify priorities for future research, policy, and practice. This article summarizes the group's conclusions. Key research priorities include identifying the active ingredients in multicomponent integrated care models and developing and validating integration performance metrics. Key policy and practice recommendations include developing new financing mechanisms and implementing strategies to build workforce and data capacity. Forum participants also highlighted an overarching need to address socioeconomic risks contributing to excess mortality among adults with serious mental illness.

Integrating Behavioral Health and Serious Illness Care in a Post-COVID-19 Environment.

Individuals with serious medical illnesses experience high rates of comorbid behavioral health conditions. Behavioral health comorbidity affects outcomes in serious illness care. Despite this consequence, behavioral health remains siloed from serious illness care. Prior to the COVID-19 pandemic, the authors presented a conceptual model of behavioral health integration into serious illness care. In this column, the authors reflect on this model in the context of the challenges and opportunities posed by COVID-19.

Measuring Seclusion in Psychiatric Intensive Care: Development and Measurement Properties of the Clinical Seclusion Checklist.

Background: Acute psychiatric units in general hospitals must ensure that acutely disturbed patients do not harm themselves or others, and simultaneously provide care and treatment and help patients regain control of their behavior. This led to the development of strategies for the seclusion of a patient in this state within a particular area separated from other patients in the ward. While versions of this practice have been used in different countries and settings, a systematic framework for describing the various parameters and types of seclusion interventions has not been available. The aims of the project were to develop and test a valid and reliable checklist for characterizing seclusion in inpatient psychiatric care. Methods: Development and testing of the checklist were accomplished in five stages. Staff in psychiatric units completed detailed descriptions of seclusion episodes. Elements of seclusion were identified by thematic analysis of this material, and consensus regarding these elements was achieved through a Delphi process comprising two rounds. Good content validity was ensured through the sample of seclusion episodes and the representative participants in the Delphi process. The first draft of the checklist was revised based on testing by clinicians assessing seclusion episodes. The revised checklist with six reasons for and 10 elements of seclusion was tested with different response scales, and acceptable interrater reliability was achieved. Results: The Clinical Seclusion Checklist is a brief and feasible tool measuring six reasons for seclusion, 10 elements of seclusion, and four contextual factors. It was developed through a transparent process and exhibited good content validity and acceptable interrater reliability. Conclusion: The checklist is a step toward achieving valid and clinically relevant measurements of seclusion. Its use in psychiatric units may contribute to quality assurance, more reliable statistics and comparisons across sites and periods, improved research on patients' experiences of seclusion and its effects, reduction of negative consequences of seclusion, and improvement of psychiatric intensive care.

Design of a Payment Decision-Support Tool for Coordinated Specialty Care for Early Psychosis.

A strengthened evidence base and earmarked federal funding have spurred the implementation of coordinated specialty care (CSC) for people experiencing early psychosis. However, existing funding mechanisms are insufficient and unsustainable to support population-wide deployment of CSC. This article describes the design framework of an innovative payment model for CSC that includes a bundled case rate payment and an optional outcome-based payment. To assist CSC payer and provider organizations in designing payment systems tailored to local preferences and circumstances, the research team is developing a decision-support tool that allows users to define design choices and provide input. The authors document the analytical algorithms underlying the tool and discuss how it could be further developed or expanded for CSC and other behavioral health interventions that feature an interdisciplinary team of clinicians and nonclinical professionals, public education and outreach, patient centeredness, and a recovery orientation.