Mobile Crisis Teams' Implementation in the Context of new Medicaid Funding Opportunities: Results from a National Survey.

This cross-sectional survey study describes characteristics of mobile crisis teams (MCTs) in the United States. Mobile crisis teams (MCTs) are increasingly recognized as essential responders to help those experiencing mental health crises get urgent and appropriate care. Recent enhanced federal funding is designed to promote adoption of MCTs, but little is known about their current structure and function and whether teams meet new Medicaid rules governing their utilization. Survey participants (N = 554) are a convenience sample of MCT representatives recruited through professional organizations, listservs, and individual email contacts from October 2021 - May 2022. Respondents most frequently identified themselves as MCT program director/manager (N = 237, 43%). 63% (N = 246) of respondents reported billing insurance for services provided (including Medicaid), while 25% (N = 98) rely on state or county general funds only. Nearly all respondents (N = 390, 98%) reported including behavioral health clinicians on their teams, and 71% (N = 281) reported operating on a 24/7 basis, both of which are required by Medicaid's enhanced reimbursement. Just over half of respondents (N = 191, 52%) reported being staffed with 11 or more FTE staff members, our estimated number required for adequate 2-person coverage on a 24/7 basis. MCTs are a popular policy initiative to reduce reliance on law enforcement to handle mental health emergencies, and enhanced federal funding is likely to expand their utilization. Federal rule makers have a role in establishing guidelines for best practices in staffing, billing, and outcomes tracking, and can help ensure that stable financing is available to improve stability in service delivery.

Implementation of the 988 Suicide & Crisis Lifeline: Estimating State-Level Increases in Call Demand Costs and Financing.

BACKGROUND: Per federal law, "988" became the new three-digit dialing code for the National Suicide & Crisis Lifeline on July 16, 2022 (previously reached by dialing "1-800-283-TALK"). AIMS OF THE STUDY: This study aimed to produce state-level estimates of: (i) annual increases in 988 Lifeline call volume following 988 implementation, (ii) the cost of these increases, and (iii) the extent to which state and federal funding earmarked for increases in 988 Lifeline call volume are sufficient to meet call demand. METHOD: A 50 state pre-post policy implementation design was used. State-level Lifeline call volume data were obtained. For each state, we calculated the absolute difference in number of Lifeline calls in the four-month periods between August-November 2021 (pre-988 implementation) and August-November 2022 (post-988 implementation), and also expressed this difference as percent change and rate per 100,000 population. The difference call volume was multiplied by a published estimate of the cost of a single 988 Lifeline call (USD 82), and then by multiplied by three to produce annual, 12-month state-level cost increase estimates. These figures were then divided by each state's population size to generate cost estimates per state resident. State-level information on the amount of state (FY 2023) and federal SAMHSA (FY 2022) funding earmarked for 988 Lifeline centers in response to 988 implementation were obtained from legal databases and government websites and expressed as dollars per state resident. State-level differences between per state resident estimates of increased cost and funding were calculated to assess the extent to which state and federal funding earmarked for increases in 988 Lifeline call volume were sufficient to meet call demand. RESULTS: 988 Lifeline call volume increased in all states post-988 implementation (within-state mean percent change = +32.8%, SD = +20.5%). The total estimated cost needed annually to accommodate increases in 988 Lifeline call volume nationally was approximately USD 46 million. The within-state mean estimate of additional cost per state resident was +USD 0.16 (SD = +USD 0.11). The additional annual cost per state resident exceeded USD 0.40 in three states, was between USD 0.40- USD 0.30 in three states, and between USD 0.30 - USD 0.20 in seven states. Twenty-two states earmarked FY 2023 appropriations for 988 Lifeline centers in response to 988 (within-state mean per state resident = USD 1.51, SD = USD 1.52) and 49 states received SAMHSA 988 capacity building grants (within-state mean per state resident = USD 0.36, SD = USD 0.39). State funding increases exceeded the estimated cost increases in about half of states. CONCLUSIONS: The Lifeline's transition to 988 increased 988 Lifeline call volume in all states, but the magnitude of the increase and associated cost was heterogenous across states. State funding earmarked for increases in 988 Lifeline center costs is sufficient in about half of states. Sustained federal funding, and/or increases in state funding, earmarked for 988 Lifeline centers is likely important to ensuring that 988 Lifeline centers have the capacity to meet call demand in the post-988 implementation environment.

Patient-, Hospital-, and System-Level Factors Associated With 30-Day Readmission After a Psychiatric Hospitalization.

ABSTRACT: Readmission after inpatient care for a psychiatric condition is associated with a range of adverse events including suicide and all-cause mortality. This study estimated 30-day readmission rates in a large cohort of inpatient psychiatric admissions in New York State and examined how these rates varied by patient, hospital, and service system characteristics. Data were obtained from Medicaid claims records, and clinician, hospital, and region data, for individuals with a diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. Psychiatric readmission was defined as any unplanned inpatient stay with a mental health diagnosis with an admission date within 30 days of being discharged. Unadjusted and adjusted odds ratios of being readmitted within 30 days were estimated using logistic regression analyses. Over 15% of individuals discharged from inpatient units between 2012 and 2013 were readmitted within 30 days. Patients who were readmitted were more likely to be homeless, have a schizoaffective disorder or schizophrenia, and have medical comorbidity. Readmission rates varied in this cohort mainly because of individual-level characteristics. Homeless patients were at the highest risk of being readmitted after discharge.

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.

Analysis of interleukin-21-induced Prdm1 gene regulation reveals functional cooperation of STAT3 and IRF4 transcription factors.

Interleukin-21 (IL-21) is a pleiotropic cytokine that induces expression of transcription factor BLIMP1 (encoded by Prdm1), which regulates plasma cell differentiation and T cell homeostasis. We identified an IL-21 response element downstream of Prdm1 that binds the transcription factors STAT3 and IRF4, which are required for optimal Prdm1 expression. Genome-wide ChIP-Seq mapping of STAT3- and IRF4-binding sites showed that most regions with IL-21-induced STAT3 binding also bound IRF4 in vivo and furthermore revealed that the noncanonical TTCnnnTAA GAS motif critical in Prdm1 was broadly used for STAT3 binding. Comparing genome-wide expression array data to binding sites revealed that most IL-21-regulated genes were associated with combined STAT3-IRF4 sites rather than pure STAT3 sites. Correspondingly, ChIP-Seq analysis of Irf4(-/-) T cells showed greatly diminished STAT3 binding after IL-21 treatment, and Irf4(-/-) mice showed impaired IL-21-induced Tfh cell differentiation in vivo. These results reveal broad cooperative gene regulation by STAT3 and IRF4.

Prioritizing quality measure concepts at the interface of behavioral and physical healthcare.

OBJECTIVE: Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care. DESIGN: We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures. SETTING: United States. PARTICIPANTS: Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates. MAIN OUTCOME MEASURES: Panelists rated measure concepts on importance, validity and feasibility. RESULTS: The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible. CONCLUSIONS: This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.

Quality Measures at the Interface of Behavioral Health and Primary Care.

The development of quality measures has gained increasing attention as health care reimbursements transition from fee-for-service to value-based payment models. As behavioral health care moves towards integration of services with primary care, specific measures and payment incentives will be needed to successfully expand access. This study uses a keyword search to identify 730 quality indicators that are relevant to behavioral health and general medical health. Measures identified have been coded and grouped into domains based on a taxonomy developed by the authors. The analysis reveals that quality measures focusing on general medical conditions exceed those focused on behavioral health diagnoses for evidence-based treatments, patient safety, and outcomes. Furthermore, measures predominantly concentrate on care during or following hospitalizations, which represents a minority of behavioral health care and does not characterize the outpatient settings that are the focus of many models of integrated care. The authors offer recommendations for future steps to identify the quality measures that can best evaluate the evolving behavioral health care system.

Are Low-Income Peer Health Coaches Able to Master and Utilize Evidence-Based Health Coaching?

PURPOSE: A randomized controlled trial found that patients with diabetes had lower HbA1c levels after 6 months of peer health coaching than patients who did not receive coaching. This paper explores whether the peer coaches in that trial, all low-income patients with diabetes, mastered and utilized an evidence-based health coaching training curriculum. The curriculum included 5 core features: ask-tell-ask, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling. METHODS: This paper includes the results of exams administered to trainees, exit surveys performed with peer coaches who completed the study and those who dropped out, observations of peer coaches meeting with patients, and analysis of in-depth interviews with peer coaches who completed the study. RESULTS: Of the 32 peer coach trainees who completed the training, 71.9% lacked a college degree; 25.0% did not graduate from high school. The 26 trainees who passed the exams attended 92.7% of training sessions compared with 80.6% for the 6 trainees who did not pass. Peer coaches who completed the study wanted to continue peer coaching work and had confidence in their abilities despite their not consistently employing the coaching techniques with their patients. Quotations describe coaches' perceptions of the training. CONCLUSIONS: Of low-income patients with diabetes who completed the evidenced-based health coaching training, 81% passed written and oral exams and became effective peer health coaches, although they did not consistently use the techniques taught.

Evaluation of methamphetamine assist packs: As-needed antipsychotics for self-management of methamphetamine-associated psychiatric toxicity.

BACKGROUND: Methamphetamine frequently causes substance-induced psychosis and related symptoms. There are currently no interventions to prevent or assist in self-management of these symptoms. METHODS: We evaluated a program providing "Methamphetamine Assist Packs" to patients who were seen in a psychiatric emergency services program for methamphetamine-induced psychosis. Methamphetamine Assist Packs included a small number of tablets of an antipsychotic medication (olanzapine), administration instructions, and referral information. We reviewed medical charts of patients who received Methamphetamine Assist Packs from January 2022 through May 2023 for sociodemographic and emergency visit characteristics. We assessed the changes between the number of psychiatric emergency visits before and after Methamphetamine Assist Pack receipt at two, six, and 12 months using generalized estimating equations. RESULTS: Ninety-two patients received a Methamphetamine Assist Pack, with a mean age of 40 years; 79 % were male and 49 % Black/African American; 77 % experienced housing instability or homelessness. The most common symptoms were suicidal ideation (54 %), paranoia or delusions (45 %), and hallucinations (40 %); 55 % were on involuntary psychiatric hold, 38 % required medications for agitation, and 18 % required seclusion or physical restraints. The rate of psychiatric emergency visits after Methamphetamine Assist Pack receipt was 0.68 and 0.87 times the rate prior to receipt at two and six months, respectively (p < 0.001). There was no difference at 12 months. CONCLUSIONS: Methamphetamine Assist Packs were associated with fewer psychiatric emergency visits for six months after receipt, and represent a promising intervention to address acute psychiatric toxicity from methamphetamine in need of further research.

Patient Flow and Reutilization of Crisis Services Within 30 Days in a Comprehensive Crisis System.

OBJECTIVE: Crisis services are undergoing an unprecedented expansion in the United States, but research is lacking on crisis system design. This study describes how individuals flow through a well-established crisis system and examines factors associated with reutilization of such services. METHODS: This cross-sectional study used Medicaid claims to construct episodes describing the flow of individuals through mobile crisis, specialized crisis facility, emergency department, and inpatient services. Claims data were merged with electronic health record (EHR) data for the subset of individuals receiving care at a crisis response center. A generalized estimating equation was used to calculate adjusted odds ratios for demographic, clinical, and operational factors associated with reutilization of services within 30 days of an episode's end point. RESULTS: Of 41,026 episodes, most (57.4%) began with mobile crisis services or a specialized crisis facility rather than the emergency department. Of the subset (N=9,202 episodes) with merged EHR data, most episodes (63.3%) were not followed by reutilization. Factors associated with increased odds of 30-day reutilization included Black race, homelessness, stimulant use, psychosis, and episodes beginning with mobile crisis services or ending with inpatient care. Decreased odds were associated with depression, trauma, and involuntary legal status. Most (59.3%) episodes beginning with an involuntary legal status ended with a voluntary status. CONCLUSIONS: Crisis systems can serve a large proportion of individuals experiencing psychiatric emergencies and divert them from more restrictive and costly levels of care. Understanding demographic, clinical, and operational factors associated with 30-day reutilization may aid in the design and implementation of crisis systems.

Telemental health policies for college students during COVID-19.

Federal and institutional policy changes have accelerated the use of telemental health to care for college students distant from their mental health providers during the early part of the COVID-19 pandemic. Temporary measures have made telemental health more readily available, including relaxing of regulations related to interstate licensure, controlled substance prescribing, patient privacy, and reimbursement. Though early efforts are underway to sustain these changes during and in the wake of the pandemic, there are important areas in which federal and institutional policy are still lacking. Additional steps are needed to successfully implement and sustain telemental health for college students include ensuring student access to technology and Internet; proactive outreach to optimize the student's home environment, addressing concerns about safety and confidentiality; developing the means to track rapidly shifting telemental health policy changes; and developing centralized resources that enable remote providers to become familiar with involuntary commitment laws and emergency protocols.

Field Visit Contact Rate by Mobile Crisis Teams as a Crisis System Performance Metric.

OBJECTIVE: The authors investigated associations between rates of contact with individuals in distress during field visits by mobile crisis teams and client and referral source characteristics. METHODS: In this retrospective observational study of an urban mobile crisis program, call logs (N=2,581) were coded for whether an attempted field visit resulted in a client evaluation. Logistic regression analyses examined potential associations with client age, gender, race-ethnicity, primary language, living situation, insurance, and referral source. RESULTS: Contact was made with 77% of adults and 97% of children referred to mobile crisis teams. Field visit contact rates differed by age. Unsuccessful visits were more likely when the referral source was from institutional settings than from individuals. CONCLUSIONS: Approximately one-quarter of attempted field visits with adults by an urban mobile crisis team were not completed, particularly among referrals from institutional settings. As mobile crisis services proliferate, field visit contact rate could be a key performance metric for these critical services.

A Rapid Review of "Low-Threshold" Psychiatric Medication Prescribing: Considerations for Street Medicine and Beyond.

OBJECTIVE: No widely accepted clinical guidelines, and scant directly applicable pragmatic research, are available to guide the prescription of psychiatric medications in "low-threshold" outpatient settings, such as street outreach, urgent care, and crisis care, as well as walk-in, shelter, and bridge and transition clinics. Providers frequently prescribe medications in these settings without patients' having firm psychiatric diagnoses and without medical records to guide clinical decision making. Persons who receive medications in these settings often seek help voluntarily and intermittently for mental illness symptoms. However, because of structural and individual factors, such patients may not engage in longitudinal outpatient psychiatric care. The authors reviewed the literature on psychiatric medication prescribing in low-threshold settings and offer clinical considerations for such prescribing. METHODS: The authors conducted a rapid literature review (N=2,215 abstracts), which was augmented with up-to-date clinical prescribing literature, the authors' collective clinical experience, and DSM-5 section II diagnostic criteria to provide considerations for prescribing medications in low-threshold settings. RESULTS: For individuals for whom diagnostic uncertainty is prominent, a symptom-based diagnostic and treatment approach may be best suited to weigh the risks and benefits of medication use in low-threshold settings. Practical considerations for treating patients with clinical presentations of psychosis and trauma, as well as mood, anxiety, and substance use disorders, in low-threshold settings are discussed. CONCLUSIONS: An urgent need exists to invest in pragmatic research and guideline development to delineate best-practice prescribing in low-threshold settings.

Community, Hospital, and Patient Factors Contributing to Ethnoracial Disparities in Follow-Up After Psychiatric Hospitalization.

OBJECTIVE: This study used an ecosocial perspective to examine ethnoracial disparities in timely outpatient follow-up care after psychiatric hospitalization in a cohort of Medicaid recipients. METHODS: This retrospective analysis used 2012-2013 New York State Medicaid claims data for 17,488 patients ages <65 years who were treated in hospital psychiatric units and discharged to the community. Claims data were linked to other administrative data sets capturing key social conditions and determinants of mental health for non-Latinx White (White hereafter), non-Latinx Black (Black), Latinx, non-Latinx Asian/Pacific Islander (Asian/Pacific Islander), non-Latinx American Indian or Native Alaskan (American Indian or Native Alaskan), and other ethnoracial groups. Regression models were used to estimate the variations in disparities in timely follow-up care that were attributable to community, organization (i.e., hospital), and individual patient characteristics. RESULTS: Overall, 60.1% of patients attended an outpatient mental health visit within 30 days of discharge. Compared with the rate for White patients, the attendance rates were 9.5 percentage points lower for Black patients and 7.8 percentage points higher for Asian/Pacific Islander patients. No significant difference in attendance rates was found between Latinx and White patients. Community factors, specifically urban versus rural classification and county poverty status, accounted for the greatest variation in timely follow-up care in all comparisons. CONCLUSIONS: Efforts to increase connection to outpatient mental health follow-up care after psychiatric hospitalization should incorporate cultural and structural competencies to address social conditions and determinants of mental health that underly ethnoracial disparities.

Impact of San Francisco's New Street crisis response Team on Service use among people experiencing homelessness with mental and substance use disorders: A mixed methods study protocol.

Mobile crisis services for people experiencing distress related to mental health or substance use are expanding rapidly across the US, yet there is little evidence to support these specific models of care. These new programs present a unique opportunity to expand the literature by utilizing implementation science methods to inform the future design of crisis systems. This mixed methods study will examine the effectiveness and acceptability of the Street Crisis Response Team (SCRT), a new 911-dispatched multidisciplinary mobile crisis intervention piloted in San Francisco, California. First, using quantitative data from electronic health records, we will conduct an interrupted time series analysis to quantitatively examine the impacts of the SCRT on people experiencing homelessness who utilized public behavioral health crisis services in San Francisco between November 2019 and August 2022, across four main outcomes within 30 days of the crisis episode: routine care utilization, crisis care reutilization, assessment for housing services, and jail entry. Second, to understand its impact on health equity, we will analyze racial and ethnic disparities in these outcomes prior to and after implementation of the SCRT. For the qualitative component, we will conduct semi-structured interviews with recipients of the SCRT's services to understand their experiences of the intervention and to identify how the SCRT influenced their health-related trajectories after the crisis encounter. Once complete, the quantitative and qualitative findings will be further analyzed in tandem to assist with more nuanced understanding of the effectiveness of the SCRT program. This evaluation of a novel mobile crisis response program will advance the field, while also providing a model for how real-world program implementation can be achieved in crisis service settings.

Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies.

How a community responds to behavioral health emergencies is both a public health issue and social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments (EDs), boarding for hours or days while waiting for treatment. Such crises also account for a quarter of police shootings and >2 million jail bookings per year. Racism and implicit bias magnify these problems for people of color. Growing support for reform provides an unprecedented opportunity for meaningful change, but solutions to this complex issue will require comprehensive systemic approaches. As communities grapple with behavioral health emergencies, the question is not just whether law enforcement should respond to behavioral health emergencies but how to reduce unnecessary law enforcement contact and, if law enforcement is responding, when, how, and with what support. This policy article reviews best practices for law enforcement crisis responses, outlines the components of a comprehensive continuum-of-crisis care model that provides alternatives to law enforcement involvement and ED use, and offers strategies for collaboration and alignment between law enforcement and clinicians toward common goals. Finally, policy considerations regarding stakeholder engagement, financing, data management, legal statutes, and health equity are presented to assist communities interested in taking steps to build these needed solutions.

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.