Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study

BACKGROUND

Despite the growing prevalence of depression and anxiety among adolescents, fewer than half access appropriate mental health care. Single-session interventions (SSIs) for depression and anxiety offered in primary care are a promising approach to bridging the treatment gap.

OBJECTIVE

We aimed to implement a clinical workflow for primary care and behavioral health providers to refer patients aged 13 to 17 years with mild to moderate depression and anxiety symptoms to Project YES (Youth Empowerment and Support), an open-access SSI platform, in a large group medical practice with an integrated behavioral health department.

METHODS

Pediatric primary care and integrated behavioral health providers will be educated on the benefits of Project YES for adolescent anxiety and depression and trained in a workflow integrated within the electronic health record system, Epic, to refer patients during well-child visits and pediatric behavioral health visits. Patients with mild to moderate internalizing symptoms based on the 17-item Pediatric Symptom Checklist or youth Pediatric Symptom Checklist will be invited to try an SSI through Project YES. We will examine provider uptake and perceptions of acceptability, feasibility, and appropriateness over time.

RESULTS

The rollout will take place between November 2022 and May 2023, when outcomes will be evaluated. Data analysis and manuscript writing are anticipated to be completed during the summer of 2023.

CONCLUSIONS

SSIs such as those available through Project YES have the potential to provide low-cost, evidence-based mental health treatment to adolescents with mild to moderate depression and anxiety. If deemed feasible and acceptable, providing SSIs in primary care settings could significantly improve access to mental health care without taxing pediatric primary care and behavioral health providers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45666.

Measurement Approaches to Estimating Methadone Continuity in Opioid Use Disorder Care

BACKGROUND

Long-term treatment with medications for opioid use disorder (OUD), including methadone, is lifesaving. There has been little examination of how to measure methadone continuity in claims data.

OBJECTIVES

To develop an approach for measuring methadone continuity in claims data, and compare estimates of methadone versus buprenorphine continuity.

RESEARCH DESIGN

Observational cohort study using de-identified commercial claims from OptumLabs Data Warehouse (January 1, 2017-June 30, 2021).

SUBJECTS

Individuals diagnosed with OUD, ≥1 methadone or buprenorphine claim and ≥180 days continuous enrollment (N=29,633).

MEASURES

OUD medication continuity: months with any use, days of continuous use, and proportion of days covered.

RESULTS

5.4% (N=1607) of the study cohort had any methadone use. Ninety-seven percent of methadone claims (N=160,537) were from procedure codes specifically used in opioid treatment programs. Place of service and primary diagnosis codes indicated that several methadone procedure codes were not used in outpatient OUD care. Methadone billing patterns indicated that estimating days-supply based solely on dates of service and/or procedure codes would yield inaccurate continuity results and that an approach incorporating the time between service dates was more appropriate. Among those using methadone, mean [s.d.] months with any use, days of continuous use, and proportion of days covered were 4.8 [1.8] months, 79.7 [73.4] days, and 0.64 [0.36]. For buprenorphine, the corresponding continuity estimates were 4.6 [1.9], 80.7 [70.0], and 0.73 [0.35].

CONCLUSIONS

Estimating methadone continuity in claims data requires a different approach than that for medications largely delivered by prescription fills, highlighting the importance of consistency and transparency in measuring methadone continuity across studies.

Measuring Behavioral Health Integration in Primary Care

Behavioral health integration (BHI) within primary care settings is shown to improve outcomes. However, achieving BHI requires identifying best practices and a reliable tool that can be used to measure existing levels and progress toward BHI. The objective of this study was to develop and apply a conceptual framework to measure BHI, test the approach, and examine challenges to achieving BHI. Surveys and interviews were conducted with key informants within 17 designated public hospitals in California at the midpoint of participating in a 5-year project to establish BHI. A framework and coding methodology were developed to assess BHI best practices at each hospital. BHI status was assessed in the domains of infrastructure and process. Each domain included 5 themes such as electronic health record integration and functionality (infrastructure) and interprovider communication (process). Themes were assessed using a 6-point scale for various activities under a theme and associated weights. Theme-specific values were standardized from 0% to 100% to compare BHI scores between hospitals. Overall progress toward BHI ranged from scores of 52% to 83% (mean 63%) and indicated greater contribution of infrastructure versus process implementation. Within the infrastructure domain, scores were higher for having institutional and provider support, but lagged in establishing provider proximity. Within the process domain, scores were highest for implementation of behavioral health screening, but were frequently lower for other themes such as use of care coordination and referral processes. Further research is needed to test the robustness of this approach in other settings.

State Policies and Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants

Nurse practitioner (NP) and physician assistant (PA) prescribing can increase access to buprenorphine treatment for opioid use disorder. In this cross-sectional study, we used deidentified claims from approximately 90% of U.S. retail pharmacies (2017-2018) to examine the association of state policies with the odds of receiving buprenorphine treatment from an NP/PA versus a physician, overall and stratified by urban/rural status. From 2017 to 2018, the percentage of buprenorphine treatment episodes prescribed by NPs/PAs varied widely across states, from 0.4% in Alabama to 57.2% in Montana. Policies associated with greater odds of buprenorphine treatment from an NP/PA included full scope of practice (SOP) for NPs, full SOP for PAs, Medicaid pay parity for NPs (reimbursement at 100% of the fee-for-service physician rate), and Medicaid expansion. Although most findings with respect to policies were similar in urban and rural settings, the association of Medicaid expansion with NP/PA buprenorphine treatment was driven by rural counties.

Implementation of collaborative psychiatric care in a family medicine clinic: A quality assurance study

In recent decades, numerous primary care clinics throughout the United States have implemented a collaborative care model of psychiatry in their practice. In this care model, patients with a psychiatric diagnosis meet with a team commonly composed of a primary care provider, behavioral health provider, and psychiatric consultants to develop a well-informed treatment plan. The St. Mary's Family Medicine Center in Grand Junction, Colorado implemented this care model in March 2020. Here, we evaluated its implementation and assessed its efficacy in producing favorable patient outcomes. We performed retrospective chart reviews and database queries in the clinic's electronic medical record system to gather relevant patient care information. We then analyzed this data through various statistical methods to assess the care model's effects on patient outcomes. Through this, we found evidence that this care model facilitates brief referral times with psychiatric specialists, and that treatment plans created here may contribute to a reduction in depressive and anxiety symptoms in a variety of patients.

Professional stakeholders' perceptions of barriers to behavioral health care following pediatric traumatic brain injury

OBJECTIVE

To examine professional stakeholders' perspectives of barriers to behavioral health care (BHC) follow-up and telepsychology after pediatric traumatic brain injury (TBI).

METHODS

Twenty-nine professionals participated in a focus group (FG) or key informant interview (KII) between January and March 2020. Professionals answered questions about facilitators and barriers to BHC follow-up and telepsychology. Given widespread telepsychology implementation since COVID-19, a follow-up survey assessing telehealth perceptions since the pandemic was sent out in December 2020. Nineteen professionals completed the survey.

RESULTS

Professionals identified individual (e.g., family factors, insurance coverage/finances, transportation/distance, availability, planning follow-up care) and system-level (e.g., lack of access to BHC providers) barriers to BHC post-injury. Possible solutions, like collaborative follow-up care, were also identified. Generally, clinical professionals have favorable impressions of telepsychology and utilized services as a delivery modality for clinical care. Though telepsychology could reduce barriers to care, professionals also expressed concerns (e.g., technology issues, security/safety) and challenges (e.g., funding, accessibility, training/licensure for clinicians) with implementing telepsychology.

CONCLUSION

Barriers identified highlight the need for context-specific solutions to increase BHC access, with telepsychology generally recognized as a beneficial modality for BHC. Future work should continue to focus on understanding barriers to BHC and potential solutions after pediatric TBI.

The Effect of National Health Service Corps Clinician Staffing on Medical and Behavioral Health Care Costs in Community Health Centers

OBJECTIVE

Prior studies of community health centers (CHCs) have found that clinicians supported by the National Health Service Corps (NHSC) provide a comparable number of primary care visits per full-time clinician as non-NHSC clinicians and provide more behavioral health care visits per clinician than non-NHSC clinicians. This present study extends prior research by examining the contribution of NHSC and non-NHSC clinicians to medical and behavioral health costs per visit.

METHODS

Using 2013-2017 data from 1022 federally qualified health centers merged with the NHSC participant data, we constructed multivariate linear regression models with health center and year fixed effects to examine the marginal effect of each additional NHSC and non-NHSC staff full-time equivalent (FTE) on medical and behavioral health care costs per visit in CHCs.

RESULTS

On average, each additional NHSC behavioral health staff FTE was associated with a significant reduction of 3.55 dollars of behavioral health care costs per visit in CHCs and was associated with a larger reduction of 7.95 dollars in rural CHCs specifically. In contrast, each additional non-NHSC behavioral health staff FTE did not significantly affect changes in behavioral health care costs per visit. Each additional NHSC primary care staff FTE was not significantly associated with higher medical care costs per visit, while each additional non-NHSC clinician contributed to a slight increase of $0.66 in medical care costs per visit.

CONCLUSIONS

Combined with previous findings on productivity, the present findings suggest that the use of NHSC clinicians is an effective approach to improving the capacity of CHCs by increasing medical and behavioral health care visits without increasing costs of services in CHCs, including rural health centers.

Comparison of Medicaid Reimbursements for Psychiatrists and Primary Care Physicians

OBJECTIVE

This study aimed to investigate whether state Medicaid programs systematically reimburse psychiatrists less than they reimburse primary care physicians.

METHODS

This study used outpatient Medicaid claims data from 2014 for 11 U.S. states. Claims with a primary behavioral health diagnosis (i.e., mental or substance use disorder) and an evaluation and management procedure code of 99213 or 99214 were identified. These are the most frequently used procedure codes by both psychiatrists and primary care physicians when treating patients with mental and substance use disorders. Average reimbursements were compared for nonfacility claims submitted by psychiatrists and primary care physicians.

RESULTS

In 9 states, psychiatrists were reimbursed less on average than primary care physicians. In one state, reimbursements were nearly equivalent.

CONCLUSIONS

Disparities in reimbursements across specialties may reduce access to psychiatric specialty care through Medicaid and are inconsistent with the Mental Health Parity and Addiction Equity Act.

A call to action to address rural mental health disparities

Rural residents in the USA experience significant disparities in mental health outcomes even though the prevalence of mental illness in rural and metropolitan areas is similar. This is a persistent problem that requires innovative approaches to resolve. Adopting and appropriately modifying the National Institute on Minority Health and Health Disparities research framework are the potential approaches to understanding how these disparities might be addressed through research. Using this research framework can facilitate interrogation of multiple levels of influence, encompassing complex domains of influence and consideration of the entire life course trajectory, which is consistent with several National Institute of Mental Health priorities.

Making Single-Payer Reform Work for Behavioral Health Care: Lessons From Canada and the United States

The claim is often made that the adoption of single-payer health care in the United States would result in dramatic improvement of services for people with mental health and substance use disorders. Evidence from this sector in countries with such frameworks is mixed, however, presenting both positive and negative lessons for an American audience. Focusing on Canada as an example, this article sheds light on this topic by drawing on sources in the professional and academic literature, government reports, news stories and features, and research on-site by the author. A concluding section highlights key policy issues that American single-payer advocates will need to address for meaningful reform of the behavioral health care sector.

Racial/ethnic disparities in specialty behavioral health care treatment patterns and expenditures among commercially insured patients in managed behavioral health care plans

OBJECTIVE

To document differences among racial/ethnic/gender groups in specialty behavioral health care (BH) utilization/expenditures; examine whether these differences are driven by probability vs intensity of treatment; and identify whether differences are explained by socioeconomic status (SES).

DATA SOURCE

The cohort consists of adults continuously enrolled in Optum plans with BH benefits during 2013.

STUDY DESIGN

We modeled each outcome using linear regressions among the entire sample stratified by race/ethnicity, language and gender. Then, we estimated logistic regressions of the probability that an enrollee had any spending/use in a given service category (service penetration) and linear regressions of spending/use among the user subpopulation (treatment intensity). Lastly, all analyses were rerun with SES controls.

DATA COLLECTION

This study links administrative data from a managed BH organization to a commercial marketing database.

PRINCIPAL FINDINGS

We found that in many cases, racial/ethnic minorities had lower specialty BH expenditures/utilization, relative to whites, primarily driven by differences in service penetration. Among women, relative to whites, Asian non-English speakers, Asian English speakers, Hispanic non-English speakers, Hispanic English speakers, and blacks had $106, $95, $90, $48, and $61 less in total expenditures. SES explained racial/ethnic differences in treatment intensity but not service penetration.

CONCLUSIONS

In this population, SES was not a major driver of racial/ethnic differences in specialty BH utilization. Future studies should explore the role of other factors not studied here, such as stigma, cultural competence, and geography.

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.

The Affordable Care Act and the Faltering Revolution in Behavioral Health Care

Often described in such terms as a "revolution" and a "game-changer" for the behavioral health sector in the United States, the Affordable Care Act has helped to enhance coverage for mental health and substance use disorders while encouraging service system innovations at the organizational level. However, tens of millions of Americans still lack health insurance, insurance companies are resisting the implementation of parity coverage rules, and inequalities in the financing and organization of care continue to worsen in key respects. This article examines these difficulties and their political-economic nature, highlighting the need for a single-payer framework if the task of reform is to be fulfilled.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees

OBJECTIVE

The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees.

METHODS

We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization.

RESULTS

MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)].

CONCLUSIONS

MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

Paving the Way to Successful Implementation: Identifying Key Barriers to Use of Technology-Based Therapeutic Tools for Behavioral Health Care

This study aimed to identify barriers to use of technology for behavioral health care from the perspective of care decision makers at community behavioral health organizations. As part of a larger survey of technology readiness, 260 care decision makers completed an open-ended question about perceived barriers to use of technology. Using the Consolidated Framework for Implementation Research (CFIR), qualitative analyses yielded barrier themes related to characteristics of technology (e.g., cost and privacy), potential end users (e.g., technology literacy and attitudes about technology), organization structure and climate (e.g., budget and infrastructure), and factors external to organizations (e.g., broadband accessibility and reimbursement policies). Number of reported barriers was higher among respondents representing agencies with lower annual budgets and smaller client bases relative to higher budget, larger clientele organizations. Individual barriers were differentially associated with budget, size of client base, and geographic location. Results are discussed in light of implementation science frameworks and proactive strategies to address perceived obstacles to adoption and use of technology-based behavioral health tools.

Behavioral Health Competence: An Exploration of Army Reserve Occupational Therapists

The behavioral health competence of Army Reserve Occupational Therapists (OT) was examined by electronic survey to determine current levels of competence and highlight pre-deployment training needs. Results indicated that while Army Reserve OTs report high levels of behavioral health competence, many questions regarding diagnosis, assessment, evaluation, treatment planning, intervention, and progress arose throughout deployment. OT's often relied on skills from Level II fieldwork education and entry-level didactic education for competency. Perceived competencies may be compromised by curriculum changes in entry-level education, available fieldwork settings, and a lack of adequate training currently available prior to deployment.