Differences in Health Care Utilization of High-Need and High-Cost Patients of Federally Funded Health Centers Versus Other Primary Care Providers.

BACKGROUND: Primary care providers (PCP) differ in their ability to address the needs and reduce use of costly services among complex Medicaid beneficiaries. Among PCPs, Health Resources and Services Administration (HRSA)-funded health centers (HCs) are shown to provide high-value care. OBJECTIVE: We compared health care utilization of complex Medicaid managed care beneficiaries whose PCPs were HCs versus 3 other groups. RESEARCH DESIGN: Cross-sectional study using propensity score matching comparing health care use by provider type, controlling for demographics, health status, and other covariates. SUBJECTS: California Medicaid administrative data for complex adult managed care beneficiaries with at least 1 primary care visit in 2018. MEASURES: Primary and specialty care evaluation & management visits and services; emergency department (ED) visits; and hospitalizations. PCPs included HCs, clinics not funded by HRSA, solo, and group practice providers. RESULTS: HRSA-funded HCs had lower predicted rates of specialty evaluation & management and other services than all others; lower predicted probability of any ED visits than clinics not funded by HRSA [54% (95% CI: 53%-55%) vs. 56% (95% CI: 55%-57%)] and group practice providers [51% (95% CI: 51%-52%) vs. 52% (95% CI: 52%-53%)]; and lower PP of any hospitalizations than solo [20% (95% CI: 19%-20%) vs. 23% (95% CI: 22%-24%)] and group practice providers [21% (95% CI: 20%-21%) vs. 24% (95% CI: 23%-24%)]. CONCLUSIONS: Differences in HC care delivery and practices were associated with lower use of specialty, ED, and hospitalization visits compared with other PCPs for complex Medicaid managed care beneficiaries. Understanding the underlying reasons for these utilization differences may promote better outcomes among these patients.

Service Utilization for Parent Management of Early Childhood Behavior Problems in a Private Outpatient Behavioral Clinic: The Impact of Out-of-Pocket Cost, Travel Distance, and Initial Treatment Progress.

Poorly-managed early childhood disruptive behavior disorders (DBDs) have costly psychological and societal burdens. While parent management training (PMT) is recommended to effectively manage DBDs, appointment adherence is poor. Past studies on influential factors of PMT appointment adherence focused on parental factors. Less well studied are social drivers relative to early treatment gains. This study investigated how financial and time cost relative to early gains influence PMT appointment adherence for early childhood DBDs in a clinic of a large behavioral health pediatric hospital from 2016 to 2018. Using information obtained from the clinic's data repository, claims records, public census and geospatial data, we assessed how owed unpaid charges, travel distance from home to clinic, and initial behavioral progress influences total and consistent attendance of appointments for commercially- and publicly-insured (Medicaid and Tricare) patients, controlling for demographic, service, and clinical differences. We further assessed how social deprivation interacted with unpaid charges to influence appointment adherence for commercially-insured patients. Commercially-insured patients had poorer appointment adherence with longer travel distances, or having unpaid charges and greater social deprivation; they also attended fewer total appointments with faster behavioral progress. Comparatively, publicly-insured patients were not affected by travel distance and had higher consistent attendance with faster behavioral progress. Longer travel distance and difficulty paying service costs while living in greater social deprivation are barriers to care for commercially-insured patients. Targeted intervention may be needed for this specific subgroup to attend and stay engaged in treatment.

Outcomes Accountability Systems for Early Childhood Disruptive Behaviors: A Scoping Review of Availability.

Early childhood disruptive behaviors are common mental health problems among American youth, and if poorly-managed, pose costly psychological and societal burdens. Outcomes accountability systems in clinical practice are vital opportunities to optimize early intervention for common mental health problems; however, such systems seem rare. A scoping review was conducted to summarize the current availability of outcomes accountability systems in clinical programs addressing early childhood disruptive behaviors, particularly in the US. We used PsycINFO to identify peer-reviewed literature published in English from 2005 to 2021, from which we selected 23 publications from the US, UK, and Netherlands on outcomes accountability systems within clinical programs treating common childhood mental health problems. Only 3 out of 23 publications described outcomes accountability efforts specifically for early childhood problems. Within the 3 studies, only one UK-based study specifically targeted early childhood disruptive behaviors. We did not find publications specifically describing outcomes accountability efforts in US-based clinical programs to treat early childhood disruptive behaviors. There are multi-level challenges preventing changes to the prevalent US model of paying a fee for each unit of child mental healthcare, with little regard for patient outcomes. However, opportunities exist to improve US-based accountability efforts; from top-down expansion of financial incentives, accountability initiatives, and PDT evidence-based practices to an iterative, bottom-up development of meaningful outcomes measurement by providers. Greater adoption of outcomes monitoring in US clinical practice for common mental health problems can optimize management of early childhood disruptive behaviors and mitigate long-term societal and economic burdens.

Clinician-Identified Factors in Success of Parent-Directed Behavioral Therapy for Children's Tantrums.

Disruptive behavior disorders (DBD) are the most common behavioral health problems in young American children. When not well-managed in early childhood, DBD can progress to lifetime mental health problems with personal, economic, as well as societal impacts. The evidence-based intervention of choice for DBD is outpatient parent-directed behavioral therapy (PDT). However, little is known about clinicians' perspectives on the factors influencing PDT's effectiveness in routine care. The current study directly assesses clinicians' perspectives on factors they believe impact PDT's success for disruptive behavior problems, in particular tantrums, at two outpatient behavioral therapy clinics specializing in PDT. In-depth interviews with 19 clinicians across three experience levels (doctoral intern, post-doctoral, licensed staff psychologist) were conducted and analyzed using qualitative methods. Two major themes were identified as enabling and limiting treatment success: (1) appointment attendance, (2) primary caregiver buy-in to treatment approach. Additional identified factors include caregiver's familial and social support, caregiver's physical and emotional capacities, complexity of the child's behavior problems, the extent to which the home environment can support positive changes, competing family/home demands, and care coordination among hospital programs. The primary factors identified by clinicians highlight the importance of fostering appointment attendance and parental psychoeducation that can be addressed by implementing multi-level administrative, training, and clinical initiatives to improve PDT's real-world effectiveness for DBD.

Maternal executive function and stress and children's behavior problem treatment outcomes.

This prospective, observational study was designed to investigate the relationship of mothers' executive function capacities and parenting stress to early dropout, appointment attendance, and outcomes of in-clinic delivery of parent management training to address children's behavior problems. We hypothesized that mothers' executive functions (EFs) would be prospectively and positively associated with adherence to children's behavioral treatment appointments and reduction in children's behavior problems and that mothers' stress levels would be inversely related to these outcomes. Mothers (n = 288) completed the Behavior Rating Inventory of Executive Function for Adults (EF) and Parenting Stress Index at the beginning of treatment. Children were 2-12 years old. Regression models evaluated the extent to which deficits in maternal EF and clinical levels of parenting stress contributed to the three outcomes. The 11% of mothers with clinically significant deficits in executive functioning were significantly (3 times) more likely to drop out early compared to mothers in the normal range. Almost one third of mothers reported clinically significant parenting stress. Their children were half as likely to achieve a positive behavior outcome, although stress was not significantly associated with attendance. Remaining in treatment is fundamental to being able to learn and practice the parenting skills necessary to manage young children's age-inappropriate behavior in positive ways. Clinical consideration of mothers' EF challenges may help prevent early treatment attrition and clinical management of parenting stress may further help improve children's treatment outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Investigating the Trajectory and Associated Risk Factors of Clinical Outcomes for Early Childhood Disruptive Behavior Disorders Using Real World Data.

Disruptive behavior disorders (DBDs) are common mental health problems among early childhood American youth that, if poorly managed, pose costly psychological and societal burdens. There is limited real world evidence on how parent management training (PMT) - the evidence-based treatment model of choice - implemented in common practice settings within the United States influences the behavioral progress of early childhood DBDs, and the risk factors associated with poor outcomes. This study used data from a measurement feedback system implemented within a U.S.-based private practice to study how behavioral outcomes change as a function of PMT treatment engagement and associated risk factors for 4-7 year-old children diagnosed with DBDs. Over 50% of patients reached optimal outcomes after 10 appointments. Attending 24-29 appointments provided maximum treatment effect - namely, 75% of patients reaching optimal outcomes by end of treatment. Outcomes attenuate after reaching the maximum effect. Patients also had higher odds of reaching optimal outcomes if they had consistent attendance throughout the treatment course. Notable risk factors associated with lower odds of reaching optimal outcomes included Medicaid insurance-type, greater clinical complexity, and having siblings concurrently in treatment. Increased implementation of systems that monitor and provide feedback on treatment outcomes in U.S.-based practice settings and similar investigations using its data can further enhance 'real world' management of early childhood DBDs among American youth.

Quantifying Population Characteristics Within and Outside a 30-Minute Drive-Time to Health Resources and Services Administration-Supported Health Centers.

The Health Resources and Services Administration's (HRSA) Health Center Program provides health care to vulnerable persons across the US, regardless of their ability to pay for health care. We examined characteristics of populations living within and outside a 30-minute drive-time to HRSA-supported health centers to establish a baseline to better understand the differences in these populations. Using a descriptive, cross-sectional study design and geographic information systems, we found that 94% of persons in the US live within a 30-minute drive-time of a health center. Of those outside a 30-minute drive-time to a health center, 11.7 million (60.11%) are rural and over 1.5 million households (20.32%) lack broadband internet access.

Retention in Outpatient Child Behavioral Health Services Among Military and Civilian Families.

Retention in treatment for children with behavior problems is critical to achieve successful outcomes, and clinical evidence suggests the behavioral health needs and retention of military-connected and civilian families differ meaningfully. Military and civilian children in outpatient behavioral treatment were compared in terms of presenting problems as well as appointment adherence (n = 446 children and their parents). Demographics and rates of externalizing behavior were similar across the two groups. More military than civilian children had internalizing problems. Military parents had more parenting distress and depressive symptoms. Fewer military families dropped out of treatment early. Within-military comparisons demonstrated that children whose parent had recently deployed were more likely to have internalizing problems and poor adaptive skills. Although retention was better among military families, the early treatment drop-out proportions (20-30%) for both groups highlight a barrier to effective behavioral intervention.