Evaluation of the SPARK Child Mentoring Program: A Social and Emotional Learning Curriculum for Elementary School Students.

Social and Emotional Learning (SEL) programs seek to enhance social and emotional competencies in children, including self-awareness, self-management, social awareness, relationship skills, and responsible decision-making. By means of direct instruction regarding social and emotional competencies, SEL programs have the potential to strengthen resilience in children and thus their capacity to effectively cope with life's challenges. Strengthening resilience in children who are repeatedly exposed to adverse experiences, particularly those from economically disadvantaged minority backgrounds, is of particular importance and has implications for the prevention of a multitude of problems later in life. Our study reports the result of an investigation of the SPARK Child Mentoring program, a resilience-focused SEL program designed to reduce risk factors, uncover innate resilience, promote natural emotional well-being, and facilitate school success. We employed a randomized controlled trial comprising 94 elementary school students that included pre- and post-intervention measurements. After controlling for pre-intervention levels, we found a significant difference between students' understanding of underlying program principles; communication, decision making, and problem-solving skills; emotional regulation; and resilience for students who received the intervention compared to students who did not receive the intervention. These results provide initial evidence for the efficacy of the SPARK Child Mentoring program with a diverse sample of elementary school students and adds to the existing literature base concerning positive outcomes associated with SEL programs. We discuss implications for future research focused on long-term preventive effects of the program and the characteristics of students most likely to benefit from it.

Adverse neonatal outcomes associated with maternal severe mental health diagnoses and opioid use.

OBJECTIVE: Determine odds ratios for neonatal abstinence syndrome (NAS) and neonatal intensive care unit (NICU) admissions for babies born to women associated with severe mental illness (SMI) and gestational opioid use. STUDY DESIGN: A retrospective pharmacoepidemiologic study using Medicaid data included 17,130 mothers with and 170,430 mothers without SMI, and their babies. Odds ratios for NAS and NICU admissions among babies born to mothers associated with SMI diagnoses and associated with varying degrees of gestational opioid use were determined using logistic regression. RESULTS: The adjusted odds ratio for a baby in the methadone or buprenorphine group having NAS was 168.93 [95% confidence interval (CI) 148.78-191.71, P < 0.001] and was 9.64 (95% CI 8.74-10.65, P < 0.001) for NICU admissions compared to babies with no opioid exposure. CONCLUSIONS: Chronicity of prescription maternal opioid use was the strongest factor associated with NAS and NICU admissions.

Individual and Organizational Factors Associated With Hospital Readmission Rates: Evidence From a U.S. National Sample.

Objective: Hospital readmission rate is an important indicator for assessing quality of care in the acute and postacute settings. Identifying factors that increase risk for hospital readmissions can aid in the recognition of potential targets for quality improvement efforts. The main objective of this brief report was to examine the factors that predict increased risk of 30-day readmissions. Method: We analyzed data from the 2013 National Readmission Database (NRD). Results: The main factors that predicted increased risk of 30-day readmission were number of chronic conditions, severity of illness, mortality risk, and hospital ownership. Unexpectedly, discharge from a for-profit hospital was associated with greater risk for hospital readmission in the United States. Discussion and Conclusion: These findings suggest that patients with severe physical illness and multiple chronic conditions should be the primary targets for hospital transitional care interventions to help reduce the rate of unnecessary hospital readmissions.

Rehospitalization risk factors for psychiatric treatment among elderly Medicaid beneficiaries following hospitalization for a physical health condition.

OBJECTIVES: Hospitalizations for physical health problems can cause great mental health challenges. We examined risk factors and expenditures for early readmission for inpatient psychiatric treatment following a hospitalization for a non-psychiatric condition. METHOD: We used eight years of Florida Medicaid enrollment and claims data for (FY 2003-2011) as well as data obtained from the Florida Center for Health Information and Policy Analysis, Inpatient Hospital Database, to identify episodes of hospitalization for all Medicaid-enrolled older adults. There were a total of 781,660 index hospitalizations for non-behavioral health-related hospitalizations, 2690 (0.3%) of which resulted in a behavioral health-related rehospitalization within 30 days after discharge. We estimated the relative risk of early rehospitalization using Cox proportional hazards regression. RESULTS: Participants (n = 276,254) were 76.8 ± 8.3 years old; 68.4% female and 43.5% White. As expected, we found that having a preexisting behavioral health disorder (including severe mental illness, substance use disorder, or dementia) greatly increased the risk of readmission. We also found that male gender increased the risk of early readmission. Older age, being Black and having one or more comorbid medical conditions as identified by the Charlson Index were associated with substantially reduced risk. CONCLUSION: Identifying hospitalized patients with psychiatric conditions, as well as those who are relatively young within this age group, male, White rather than Black or of other race, alcohol abusers, and those without comorbid conditions, and providing them with care to address their behavioral needs may help in efforts to reduce early rehospitalizations for psychiatric conditions.

Risk of Early Rehospitalization for Non-Behavioral Health Conditions Among Adult Medicaid Beneficiaries with Severe Mental Illness or Substance Use Disorders.

The goal was to examine risk factors and expenditures for early rehospitalization (within 30 days of discharge) for non-behavioral health conditions among Medicaid-enrolled Floridians over 8 years. There were 1,689,797 hospitalization episodes with 19% (N = 314,742) resulting in early rehospitalization. Total gross charges for early rehospitalization were over 13 billion dollars. In Cox proportional hazards regression adjusted for demographic and health covariates, drug use disorder was associated with 50% increased risk of early rehospitalization. Having major depressive disorder increased risk by 17%; psychotic disorder, bipolar disorder, and alcohol use disorder increased risk of early rehospitalization slightly by 10, 6, and 6% respectively. The effect of dementia on risk was minimal at 2%. Risk of early rehospitalization decreased by 3.5% per year over the 8 years of the study. Attention to mental health problems, especially drug use disorder, may help further reduce rates of early readmission for non-behavioral health conditions.

Risk factors for early readmission to acute care for persons with schizophrenia taking antipsychotic medications.

OBJECTIVE The study examined risk factors for readmission to acute care among Florida Medicaid enrollees with schizophrenia treated with antipsychotics. METHODS Medicaid and service use data for 2004 to 2008 were used to identify adults with schizophrenia discharged from hospitals and crisis units who were taking antipsychotics. Data were extracted on demographic characteristics, service use before admission, psychopharmacologic treatment after discharge, and readmission to acute behavioral health care. Cox proportional hazards regression estimated readmission risk in the 30 days after discharge and in the period after 30 days for participants not readmitted in the first 30 days. RESULTS The mean±SD age of the 3,563 participants was 43.4±11.1; 61% were male, and 38% were white. Participants had 6,633 inpatient episodes; duration of hospitalization was 10.6±7.0 days. Readmission occurred for 84% of episodes, 23% within 30 days. Variables associated with an increased readmission risk in the first 30 days were shorter hospitalization (hazard ratio [HR]=1.18, 95% confidence interval [CI]=1.10-1.27, p<.001), shorter time on medication before discharge (HR=1.19, CI=1.06-1.35, p=.003), greater prehospitalization use of acute care (HR=2.64, CI=2.29-3.05, p<.001), serious general medical comorbidity (HR=1.21, CI=1.06-1.38, p=.005), and prior substance abuse treatment (HR=1.58, CI=1.37-1.83, p<.001). After 30 days, hospitalization duration and time on medication were not significant risk factors. CONCLUSIONS Short hospital stays for persons with schizophrenia may be associated with risk of early readmission, possibly because the person is insufficiently stabilized. More chronic risk factors include prior acute care, general medical comorbidity, and substance abuse.

Predictors of emergency commitment for nursing home residents: the role of resident and facility characteristics.

OBJECTIVES: The ability of nursing homes to manage the mental health needs of their residents is crucial to providing high quality care. An important element is preventing exacerbations of psychiatric conditions that trigger discharge from the nursing home (NH) because of an emergency commitment (EC) for an involuntary psychiatric examination. The objective of this study was to examine the relationship between resident and facility characteristics and the risk of EC for involuntary psychiatric examination among Medicaid-enrolled NH residents in Florida. DESIGN: This retrospective cohort study employed 2.5 years (31 December 2002 through 30 June 2005) of Medicaid enrollment and fee-for-service, pharmacy, and involuntary commitment data to examine resident characteristics. NH characteristics were obtained from the Online Survey Certification and Reporting database. SETTING: Medicaid-certified NHs in Florida (N= 584). PARTICIPANTS: Medicaid-enrolled NH residents (N= 32,604). RESULTS: Younger age, male gender, having dementia, having a serious mental illness (SMI), and residing in a for-profit facility were all independently associated with the greater risk of EC. Although most residents with EC were prescribed psychotropic medication, less than half received non-pharmacological behavioral health outpatient services before or after their involuntary psychiatric examination. CONCLUSION: Our findings highlight the salience of resident and facility characteristics to prevalence rates of EC for involuntary psychiatric examinations among NH residents and underscore a need for increased education, communication, and future research on the predictive factors as well as the consequences of these adverse events.

Predictors of avoidable hospitalizations among assisted living residents.

OBJECTIVES: Hospitalizations for long term care residents, including those from assisted living facilities (ALFs), are very costly, often traumatic, and increase risk for iatrogenic disorders for those involved. Currently, hospital expenditures account for approximately one-third of total national health care spending. Hospitalizations for ambulatory care-sensitive (ACS) conditions are considered potentially avoidable, as these are physical health conditions that can often be treated safely at a lower level of care or occur as a result of lack of timely, adequate treatment at a lower level of care. The goal was to examine risk factors for hospitalization for an ACS condition of Medicaid-enrolled younger and older ALF residents during 2003-2008. DESIGN: This is a retrospective cohort study that used 5 years of Medicaid enrollment and fee-for-service claims data. PARTICIPANTS: The study sample included 16,208 Medicaid-enrolled ALF residents in Florida, 7991 (49%) of whom were 65 years of age or older. RESULTS: In total, study participants had 22,114 hospitalizations, 3759 (17%) of which were for an ACS condition. Sixteen percent of all ALF residents (n = 2587), about 12% of the younger residents and 20% of the older residents, had at least one ACS hospitalization. ACS hospitalizations constitute 13% of all hospitalizations for the younger residents and 22% of all hospitalizations for the older residents. Using Cox proportional hazard regression, we found that for both age groups, increased age, being Hispanic or of other race/ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. For older residents, having a dementia diagnosis and being African American reduced the risk of ACS hospitalization, whereas for younger residents having a major psychotic disorder reduced the risk of ACS hospitalization. CONCLUSION: The results highlight the need for increased education, communication, and future research on these predictive factors. The increased frequency of hospitalization for ACS conditions among ALF residents with minority status and older age may well indicate that their more complex health care needs are not being adequately addressed. The role of serious mental illness and dementia in risk for ACS hospitalization also deserves further attention.

Factors related to criminal justice expenditure trajectories for adults with serious mental illness.

BACKGROUND: Criminal careers have been extensively studied in general population sample, but less is known about such patterns among people with major mental illness, and where so, criminal justice expenditure has not been taken into account. AIMS: Our aim was to examine criminal justice system expenditure over time in one Florida county. Our main research question was whether treatment for mental disorders was related to a change in criminal offending and expenditure trajectory. METHODS: We used the Pinellas County (Florida) Criminal Justice Information System to identify individuals under age 65 arrested between July 2003 and June 2004. Archival medical service, social and homeless services data were used to identify individuals with a serious mental illness. A two-step analysis was used to examine the data: first, we identified groups of people with similar patterns of criminal justice expenditures over 4 years (July 2002 to June 2006); second, we evaluated their demographic characteristics, diagnosis and treatment as potential predictors of group membership. RESULTS: Three thousand seven hundred sixty-nine people with serious mental illness were identified in the Pinellas County jail population. Their average length of stay in jail was 151 days and in prison was 48 days. The trajectory analysis identified three groups of individuals with distinct trajectories of criminal justice expenditures: those with low stable, those with initially high but decreasing and those with initially high and sustained or increasing. Mental health treatment, whether acute or sustained, voluntary or mandatory, was associated with membership of the low stable group. CONCLUSION: Review of criminal justice expenditure over time on individuals with major mental disorder may provide important indicators of unmet need for mental health services. Furthermore, it seems probable that improved provision of such services for them could reduce recidivism as well as improving health. Interventions may also be better focused if criminal justice expenditure trajectories are examined; programmes targeting re-offending as well as specific mental health problems may be most effective.

Risk of arrest in persons with schizophrenia and bipolar disorder in a Florida Medicaid program: the role of atypical antipsychotics, conventional neuroleptics, and routine outpatient behavioral health services.

OBJECTIVE: To examine (1) arrest outcomes for adults with schizophrenia and bipolar disorder who were treated with first-generation antipsychotics (FGAs) or second-generation atypical antipsychotics (SGAs) and (2) the interaction between medication class and outpatient services in a Florida Medicaid program. METHOD: In a secondary data analysis, Florida Medicaid data covering the period from July 1, 2002, to March 31, 2008, were used to identify persons diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder and to examine antipsychotic medication episodes lasting at least 60 days. There were 93,999 medication episodes in the population examined (N = 36,519). Medication episodes were coded as (1) SGA-aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, risperidone, risperidone long-acting therapy, or ziprasidone; or (2) FGA-any other antipsychotic medication. Outpatient services were defined as the proportion of 30-day periods of each medication episode with at least 1 behavioral health visit. Survival analyses were used to analyze the data, and they were adjusted for the baseline propensity for receiving an SGA. RESULTS: Second-generation antipsychotic episodes were not associated with reduced arrests compared to FGA episodes; however, the interaction between outpatient services and SGA episodes was significant (hazard ratio [HR] = 0.68; 95% CI, 0.50-0.93; P = .02) such that an SGA episode with an outpatient visit during at least 80% of every 30-day period of the episode was associated with reduced arrests compared to SGA episodes with fewer outpatient services. There was no significant effect for concurrent FGA episodes and outpatient treatment (HR = 0.81; 95% CI, 0.60-1.10; P = .18). Substance use, poor refill compliance, and prior arrest increased risk of subsequent arrest. CONCLUSIONS: The interaction between outpatient visits and treatment with SGAs was significantly associated with reduced arrests. These findings indicate the importance of concurrent antipsychotic medications and outpatient services to affect arrest outcomes for adults with schizophrenia and bipolar disorder.

Gender differences and risk of arrest among offenders with serious mental illness.

Despite the increasing number of men and women with serious mental illness (SMI) incarcerated in America's jails, little research exists on the role gender may play in arrest among persons with SMI. This study examined correlates of arrests among offenders with SMI, specifically the role of gender. County criminal justice records, as well as county and statewide social service archival databases, were used to identify jail inmates with SMI in a large urban county in Florida. Of the 3,769 inmates identified, 41% were female. This study identified three distinct classes of male and female offenders within which persons had similar trajectories of arrests over the 4-year study period representing those with minimal, low, and high arrest rates. Findings suggest some important differences between women and men in risk factors for re-arrests. Attention to these factors may improve the ability to prevent future recidivism among men and women with SMI.

Risperidone long-acting therapy prescribing patterns and their impact on early discontinuation of treatment in a large Medicaid population.

OBJECTIVE: Medicaid claims were examined to determine whether utilization of risperidone long-acting therapy (LAT) was consistent with manufacturer's prescribing information recommendations and what factors were associated with early discontinuation. METHOD: Florida Medicaid claims between July 1, 2003, and June 30, 2007, were used. Recipient demographics and diagnoses, provision of oral antipsychotic supplementation during the first 21 days, number of injections received, medication possession ratio, and augmentation/polypharmacy after the first 21 days were assessed. Logistic regression was used to identify factors associated with early discontinuation of risperidone LAT. RESULTS: There were 3,364 individuals who received 4,546 episodes of risperidone LAT. Most recipients were between 18 and 64 years and had schizophrenia or schizoaffective disorder. Median episode length was 106 days. Median number of injections was 5. Supplementation with oral antipsychotic during the first 21 days was provided in 48% of episodes. Mean dosages were 25 mg or less for 28% of episodes and greater than 75 mg for 7% of episodes. Augmentation/polypharmacy after the first 21 days occurred in 43% of episodes. Early risperidone LAT discontinuation was associated with absence of oral supplementation during the first 21 days (P < .001), low (P = .045) or high (P < .001) initial doses of risperidone LAT, prior inpatient treatment (P < .001), having a substance use disorder (P = .001), and being male (P = .036). CONCLUSIONS: Prescribing practices for risperidone LAT were compared with the recommended protocol. Risperidone LAT was typically used with recommended age and diagnostic groups. However, important discrepancies were identified that could have reduced perceived effectiveness and tolerability of risperidone LAT. Early discontinuation was less likely when the recommendations in the manufacturer's prescribing information regarding dosage and supplementation with oral antipsychotics were followed.

Short-term impact of preferred drug list changes on health care use and Medicaid costs: injectable risperidone.

OBJECTIVE: This study assessed short-term effects of the removal of injectable risperidone long-acting therapy from the Florida Medicaid preferred drug list (PDL) in April 2006. METHODS: A difference-in-difference approach was used to contrast changes (60 days pre and post) in health care utilization and costs of Medicaid recipients who were receiving risperidone long-acting therapy when the policy was changed (N=247) and of a matched sample who received risperidone long-acting therapy in April 2005 (non-PDL, N=247). RESULTS: The policy change was associated with increased acute care events. Whereas acute care events declined for the non-PDL group, involuntary commitments and total acute care events increased for the PDL group, as did expenditures for crisis-related events. Medicaid pharmacy costs fell for both groups, but total expenditures did not decline significantly for the PDL group. CONCLUSIONS: The PDL restriction was associated with increased acute care events and did not reduce short-term Medicaid program expenditures.

Antipsychotic polypharmacy in the treatment of children and adolescents in the fee-for-service component of a large state Medicaid program.

OBJECTIVES: The aims of this study were to quantify and describe antipsychotic polypharmacy use among patients aged 6 to 12 years (children) and 13 to 17 years (adolescents) and to identify the characteristics of polypharmacy recipients. METHODS: Data from patients enrolled in Florida's Medicaid fee-for-service program and receiving treatment with an antipsychotic were included. Antipsychotic polypharmacy was defined as the receipt of > or = 2 antipsychotic medications concurrently for >60 days, with no gaps >15 days in polypharmacy treatment. The prevalence of antipsychotic polypharmacy, durations of treatment episodes, times to antipsychotic polypharmacy after initiation of antipsychotic monotherapy, and rates of antipsychotic combination use were calculated for the period between July 2002 and June 2007. RESULTS: During the 5-year period, 12,764 children and 10,419 adolescents received antipsychotic treatment. The proportions of patients who were male (73% and 63%) and whose race was indicated as "other" (31% and 14%) were significantly greater in children than in adolescents, respectively (both, P < 0.001). Seven percent of the children and 8% of the adolescents were prescribed antipsychotic polypharmacy (P = 0.001). Mean (SD) durations of polypharmacy episodes were 170.0 (139.0) days in children and 185.5 (175.9) days in adolescents (P = 0.010). Times to initiation of polypharmacy were 505.8 (440.5) days in children and 384.9 (424.3) days in adolescents (P < 0.001). Adolescents (odds ratio [OR] = 1.16; 95% CI, 1.04-1.29) were more likely than children to be polypharmacy recipients, as were those with psychotic disorders (OR = 1.47; 95% CI, 1.20-1.81) compared with those with bipolar I disorder. Patients whose race was indicated as "other" were more likely than patients of white race to receive polypharmacy (OR = 1.18; 95% CI, 1.04-1.34; P < 0.001); other ethnic/racial groups did not differ significantly. The most common specific antipsychotic combinations prescribed in children and adolescents were aripiprazole/quetiapine (23% and 17%, respectively), risperidone/quetiapine (18% and 15%), aripiprazole/risperidone (17% and 11%), risperidone/olanzapine (5% and 6%), and quetiapine/olanzapine (4% and 7%). CONCLUSIONS: The prevalence and duration of Antipsychotic polypharmacy among antipsychotic recipients in this Medicaid fee-for-service population were noteworthy. Research on the risks and benefits of the practice in the pediatric population is needed.

Characteristics and experiences of adults with a serious mental illness who were involved in the criminal justice system.

OBJECTIVE: This study identified characteristics and experiences of arrestees and jail inmates with a serious mental illness that were associated with misdemeanor and felony arrests and additional days in jail. METHODS: County and statewide criminal justice records and health and social service archival data sets were used to identify inmates with serious mental illness who were in the Pinellas County, Florida, jail between July 1, 2003, and June 30, 2004, and their health and social service contacts from July 1, 2002, to June 10, 2006. Criminal justice and mental health services were recorded longitudinally across 16 quarters, or 90-day periods. Generalized estimating equations for count data were used to describe the associations between individual characteristics and experiences and the risks of misdemeanor and felony arrests and additional days in jail. RESULTS: A total of 3,769 jail inmates (10.1% of all jail inmates) were diagnosed as having a serious mental illness. Participants experienced a mean+/-SD of .90+/-.60 arrest for every three quarters and 10.9+/-23.6 days in jail per quarter that they resided in the county. Being male, being homeless, not having outpatient mental health treatment, and having an involuntary psychiatric evaluation in the previous quarter were independently associated with significantly increased odds of misdemeanor arrests and additional days in jail. On the other hand, being black, being younger than 21 years, having a nonpsychotic diagnosis, and a co-occurring substance use disorder diagnosis were all independently associated with significantly increased odds of felony arrests, and with the exception of having a nonpsychotic diagnosis, they were also significantly associated with additional days in jail. CONCLUSIONS: Findings suggest that there are subgroups of individuals with a serious mental illness in the criminal justice system that may require different policy and programmatic responses.

Predictors of preventable nursing home hospitalizations: the role of mental disorders and dementia.

OBJECTIVES: Nursing home (NH) hospitalizations place an enormous economic burden on an already overtaxed American healthcare system. Hospitalizations for "ambulatory care-sensitive" (ACS) conditions are considered preventable, as these are physical health conditions that can potentially be treated safely in a NH. The authors examined risk factors, including mental disorders and dementia, for hospitalization of Medicaid-enrolled NH residents with ACS conditions during fiscal year 2003-2006. METHODS: The authors merged Medicaid claims and enrollment data and Online Survey Certification and Reporting information for 72,251 Medicaid-enrolled NH residents in 647 NHs in Florida. The authors identified at least one ACS hospitalization in 8,382 residents for a total of 10,091 hospital admissions (18.5% of all hospitalizations). The authors used Cox proportional hazard regression to assess time to the first ACS hospitalization. RESULTS: In a fully adjusted model, younger age, non-white race, dementia, and serious mental disorder were associated with greater risk of ACS hospitalization. In addition, residents with a diagnosed mental disorder and no dementia incurred relatively high expenditures for ACS hospitalizations. Among facility characteristics, participants from for-profit facilities, facilities that were not a member of a chain, had more Medicaid recipients, and fewer than 120 beds had greater risk of ACS hospitalizations. CONCLUSIONS: Attention to the identified predictors of hospitalization for ACS conditions, which are potentially preventable, could reduce the risk and cost of these hospitalizations among Medicaid-enrolled NH residents. The need to reduce unnecessary hospitalization will become only more urgent as the population ages and healthcare expenses continue to escalate.

The association of individual and facility characteristics with psychiatric hospitalization among nursing home residents.

OBJECTIVE: To examine resident and facility characteristics associated with psychiatric hospitalizations (PH) for Medicaid enrolled nursing home (NH) residents. METHODS: Participants were all Medicaid enrolled NH residents (n = 32,604) from all Medicaid certified nursing homes in Florida (n = 584) with complete data. We used individual demographic and diagnostic characteristics, as well as facility characteristics, to explore risk of psychiatric hospitalization in this dataset. RESULTS: Using generalized estimating equations, we found that younger age, male gender, poor physical health, serious mental illness, dementia, and drug use disorder were associated with risk of psychiatric hospitalization. Most notably, residents under 65 were more than three times more likely to undergo psychiatric hospitalization and dementia was associated with a three-fold increase in the risk of psychiatric hospitalization. Predictors of PH differed somewhat for younger and older residents. Among facility characteristics, greater facility size, low proportion of those paying via Medicare and high proportion of residents with serious mental illness were associated with increased risk of psychiatric hospitalization, whereas, low proportion of residents paying via Medicaid, high proportion of residents paying via Medicare, and low proportion of resident with serious mental illness were associated with reduced risk. CONCLUSIONS: Both resident and facility characteristics impact risk for psychiatric hospitalization. Attention to identified predictors may reduce risk and improve outcomes for nursing home residents.