Implementing an E-prescribing system in outpatient mental health programs.

This study describes the implementation and evaluation of an electronic prescription ordering system and feedback report in three community-based mental health outpatient agencies and the usefulness of the system in improving psychiatrists' prescribing behavior. Using the e-prescribing system as a data collection tool, feedback on evidence based prescribing practices for patients diagnosed with schizophrenia spectrum disorder or major affective disorder was provided to agency directors and prescribers via a monthly report. The results of the project were that e-prescribing tools can be installed at a reasonable cost with a short start up period. Although the feedback intervention did not show a significant reduction in questionable prescribing patterns, we should continue to investigate how to best use HIT to improve safety, reduce costs, and enhance the quality of healthcare. A better understanding of what prescribers find useful and the reasons why they are prescribing non-evidenced based medications is needed if interventions of this type are to be effective. Given the availability of administrative claims data and electronic prescribing technology, considerable potential exists to provide useful information for monitoring and clinical decision making in public mental health systems.

[Intentional peer support]. / El apoyo de pares intencional.

In this paper, we will describe the core themes behind the practice of Intentional Peer Support (IPS), offering a unique perspective on what has commonly been described as "mental illness" and the power dynamics inherent in traditional helping relationships. Through intentional conversations that explore "how we've come to know what we know" and challenge the naming of our experience by others, we begin to find new ways of understanding and responding to our own and other people's experiences. In addition, we emphasize the importance of mutuality in relationships. Both people share responsibility for the relationship, and no one is assumed to be the sole holder of "truth". Mutuality becomes harder but even more critical to practice when we begin to fear for "safety" of the other. It is our belief that as we practice IPS across all relationships in our lives, we can begin to tackle some of the complex ways in which language, roles, power and culture have contributed to our own sense of internalized oppression in any form.

El apoyo de pares intencional / [Intentional peer support].

In this paper, we will describe the core themes behind the practice of Intentional Peer Support (IPS), offering a unique perspective on what has commonly been described as "mental illness" and the power dynamics inherent in traditional helping relationships. Through intentional conversations that explore "how we’ve come to know what we know" and challenge the naming of our experience by others, we begin to find new ways of understanding and responding to our own and other people’s experiences. In addition, we emphasize the importance of mutuality in relationships. Both people share responsibility for the relationship, and no one is assumed to be the sole holder of "truth". Mutuality becomes harder but even more critical to practice when we begin to fear for "safety" of the other. It is our belief that as we practice IPS across all relationships in our lives, we can begin to tackle some of the complex ways in which language, roles, power and culture have contributed to our own sense of internalized oppression in any form.

El apoyo de pares intencional. / [Intentional peer support].

In this paper, we will describe the core themes behind the practice of Intentional Peer Support (IPS), offering a unique perspective on what has commonly been described as "mental illness" and the power dynamics inherent in traditional helping relationships. Through intentional conversations that explore "how weve come to know what we know" and challenge the naming of our experience by others, we begin to find new ways of understanding and responding to our own and other peoples experiences. In addition, we emphasize the importance of mutuality in relationships. Both people share responsibility for the relationship, and no one is assumed to be the sole holder of "truth". Mutuality becomes harder but even more critical to practice when we begin to fear for "safety" of the other. It is our belief that as we practice IPS across all relationships in our lives, we can begin to tackle some of the complex ways in which language, roles, power and culture have contributed to our own sense of internalized oppression in any form.

Implementing the illness management and recovery program in Japan.

OBJECTIVE: This study investigated the feasibility and outcomes of the illness management and recovery program in Japan. METHODS: Thirty-five patients with schizophrenia were recruited. Participants were assigned (not randomly) to the intervention and wait-list comparison groups. Symptom severity, functioning, activation level in self-management, quality of life, satisfaction, self-efficacy in community living, and satisfaction with services were measured before and after the intervention. RESULTS: Over two years 25 patients completed the intervention (some after being wait-listed). In the pre-post comparison, they showed significant improvement in symptoms and functioning, self-reported activation in self-management, quality of life, satisfaction, and self-efficacy in community living. Compared with the ten participants in a wait-list comparison group, the eight participants in the first intervention group showed an increased quality of life in social functioning, satisfaction in living, and self-efficacy for social relationships in community living. CONCLUSIONS: Findings suggest that the program is effective for participants with severe mental illness in Japan.

Distance matters in choice of mental health program: policy implications for reducing racial disparities in public mental health care.

The purpose of this study is to examine the influence of race, geographic distance and quality on the choice of community mental health programs. The study population was comprised of adult Medicaid recipients who received outpatient treatment for serious mental illness in FY 2001. A discrete choice model was employed to examine the likelihood of choosing one program over another. Quality was measured based on follow-up after hospital discharge and continuity of care in outpatient services. Maps showing the relationship between race and the quality of care were prepared to visually confirm the results of the statistical analysis. African American and Hispanic clients were less likely to travel further for treatment, while no significant difference was found between the Caucasian and other race groups. Caucasian subjects were more likely to choose programs with a higher quality of care compared to Hispanic or African American clients. Higher income clients were, on average, traveling longer and receiving better quality of care after controlling for race. The results suggested that clients living in higher income White neighborhoods are more likely to travel longer distances for mental health treatment. Special attention must be paid to improve the quality of care in lower income minority neighborhoods to insure equity of treatment in publicly funded programs.

Costs of implementing a computerized prescription system in a public mental health agency.

OBJECTIVE: The objective of this case report is to inform decision makers about costs associated with adding a computerized prescription component to an existing information system in specialty mental health agencies. METHODS: A computerized prescription system was implemented in four not-for-profit mental health agencies in an urban setting as part of a larger study looking at reducing racial disparities. This brief report describes the implementation costs at one agency with ten full-time-equivalent psychiatrists for which information was available on time devoted to implementation by the management information system personnel. The financial costs of the computer network hardware and software were also documented. RESULTS: The total initial cost was $27,607: preimplementation cost, $3,720; technology and system integration cost, $10,148; and training cost, $13,739. Annual ongoing cost was expected to be $14,725. CONCLUSIONS: The technology expenditure itself is not prohibitive for initial implementation as well as for ongoing support.

Comparison of alcohol treatment and costs after implementation of medicaid managed care.

OBJECTIVE: To examine the impact of a mandatory managed care behavioral health program on utilization and cost of alcohol treatment services for high-risk Medicaid patients. STUDY DESIGN: Pre-post nonequivalent comparison group design to compare managed care clients with fee-for-service (FFS) clients in terms of behavioral treatment costs and use. METHODS: Study subjects were adult Medicaid enrollees diagnosed with alcohol abuse or alcohol dependence. Chi-square tests and analysis of variance were used to determine significant differences between managed care and FFS programs in characteristics of the subjects, service use rates, and intensity of care. A regression model was used to examine predisposing, enabling, and need factors that might explain cost differences between programs. RESULTS: The managed care site had reduced behavioral healthcare costs compared with the FFS site. However, the regression analysis, which explained 35% of the variance in behavioral health service cost per user, showed that treatment cost was not significantly lowered by the managed care intervention once predisposing and need factors were controlled for. Nineteen percent of the variance in cost was explained by increased mental health comorbidity and 12% by drug comorbidity. CONCLUSION: Consistent with other studies, the results show lower behavioral healthcare costs after the managed care intervention because of changes in management practices, service substitution, and negotiation of lower hospital fees. However, the managed care influence was insignificant in explaining cost variation between sites due to higher morbidity in the FSS site post managed care.

Living arrangements of individuals with schizophrenia in Japan: impact of community-based mental health services.

AIMS: In Japan psychiatric hospitals and family play the predominant roles in caring for people with serious mental illness. This study explored how the introduction of community-based care has changed this situation by examining living arrangements of individuals with schizophrenia who were treated in one of the most progressive systems in Japan (Kawasaki) compared with national norms. METHODS: The proportion of clients with schizophrenia in the community versus hospital and living arrangements for those in the community were compared between the Kawasaki and national treated population, using data from the Kawasaki psychiatric service users survey in 1993 and two national surveys in 1993 and 1983. The variation in living arrangements was examined across five different age cohorts. RESULTS: The estimated national population was 36.7, which was similar to 32.7 clients per 10,000 population in Kawasaki. Some 71% of the Kawasaki clients were treated in the community compared with 55% nationally. The difference between the Kawasaki and national populations was the largest among clients aged 40 to 59. The Kawasaki community clients had a higher proportion of clients living alone. CONCLUSIONS: The community mental health services available in Kawasaki appeared to reduce hospitalisation and help clients to live alone in the community.

A service system planning model for individuals with serious mental illness.

An institutional-based care system in mental health has been replaced by a network of community-based services with different levels of structure and support. This poses both an opportunity and a challenge to provide appropriate and effective care to persons with serious mental illnesses. This paper describes a simulation-based approach for mental health system planning, focused on hospital and residential service components that can be used as a decision support tool. A key feature of this approach is the ability to represent the current service configuration of psychiatric care and the client flow pattern within that framework. The strength of the simulation model is to help mental health service managers and planners visualize the interconnected nature of client flow in their mental health system and understand possible impacts of changes in arrival rates, service times, and bed capacity on overall system performance. The planning model will assist state mental health agencies to respond to requirements of the Olmstead decision to ensure that individuals with serious mental illness receive care in the least restrictive setting. Future plans for refining the model and its application to other service systems is discussed.

The effect of income and race on quality of psychiatric care in community mental health centers.

This study examined the relationship between quality of mental health care provided by community mental health centers (CMHCs) and the poverty and racial mix of neighborhoods. Indicators of quality of care were constructed by examining service mix and prescription patterns for adult patients with schizophrenia during fiscal year 1996. CMHCs in high income, Caucasian areas were found to have higher quality of care indicators than those in low income, African American areas; i.e., higher percentage of patients on atypical antpsychotic prescriptions (47% vs. 33%) and higher percentage using intensive case management (ICM) services (67% vs. 29%). Questions arise regarding the factors underlying this phenomena and the extent to which they are provider-driven or due to patient preferences.

Effects of antipsychotic medication on psychiatric service utilization and cost.

BACKGROUND: Based on randomized clinical trials, consensus has been emerging that the first line of treatment for individuals with psychotic disorders should be the newer atypical or second generation antipsychotic medications rather than the older neuroleptics. Given that acquisition costs of atypical antipsychotics are generally higher than typical antipsychotics, uncertainty exists whether the newer atypicals are cost effective alternatives when used in ordinary practice settings. AIMS OF THE STUDY: The introduction of newer atypical antipsychotic agents has prompted evaluation of their overall effectiveness in reducing health care costs given their higher acquisition costs. This paper focuses on the effects of differing classes of atypical versus typical antipsychotic medications on psychiatric service utilization and cost for persons with serious mental illness treated in usual practice settings. METHODS: Descriptive statistics are used to compare patient characteristics, service rates and costs across psychotropic medication groups. Prediction equations employing ordinary least squares regression models are used to explain variation in cost due to pharmacy group membership controlling for demographics, clinical diagnoses and symptoms. Subjects were 338 Medicaid clients with serious mental illness from Florida, Pennsylvania and Oregon treated in ordinary clinical settings. Resource utilization and costs were operationalized using administrative databases to measure consumption of treatment services and pharmaceuticals for a six month period. RESULTS: Inpatient service use was significantly higher for individuals on atypical only and combination atypical/typical medications compared to those on typical medications only, whereas outpatient use was highest for those on typicals. Furthermore, six-month costs for both pharmacy and psychiatric services were significantly greater for persons in the atypical only (USD 6528) and combination typical/atypical groups (USD 6589) compared to those on typicals only (USD 3463). There were still significantly higher costs associated with atypical only and the combination typical/atypical users after multivariate controls were used. DISCUSSION: This study showed that Medicaid clients in community settings using atypical only and typical/atypical combination medications had the highest costs both in pharmacy and service use when compared to those on typical only medications. However, this study design does not allow us to ascribe a causal relationship between medication group and service costs. Given that olanzapine was the most recent medication in the compendium of available drugs at the time of this study, it is possible that those in the olanzapine only group were failing on other drugs. Caution must be used in drawing policy implications regarding cost effectiveness of newer medications since individuals who are getting the newer atypical or combination medications in community mental health center settings may be unstable on the older medications. IMPLICATIONS FOR FUTURE RESEARCH: A longer follow-up period is needed to determine if the cohort remaining on current atypical medications stabilize over time while those taking the newest drug on the market become the most costly population.

Modeling patient flows using a queuing network with blocking.

The downsizing and closing of state mental health institutions in Philadelphia in the 1990's led to the development of a continuum care network of residential-based services. Although the diversity of care settings increased, congestion in facilities caused many patients to unnecessarily spend extra days in intensive facilities. This study applies a queuing network system with blocking to analyze such congestion processes. "Blocking" denotes situations where patients are turned away from accommodations to which they are referred, and are thus forced to remain in their present facilities until space becomes available. Both mathematical and simulation results are presented and compared. Although queuing models have been used in numerous healthcare studies, the inclusion of blocking is still rare. We found that, in Philadelphia, the shortage of a particular type of facilities may have created "upstream blocking". Thus removal of such facility-specific bottlenecks may be the most efficient way to reduce congestion in the system as a whole.

Long-term effectiveness of the ACCESS program in linking community mental health services to homeless persons with serious mental illness.

This study examined the long-term effectiveness of the ACCESS (Access to Community Care and Effective Services and Supports) project on service utilization and continuity of care among homeless persons with serious mental illness. A 3-year longitudinal analysis, using Medicaid claims data, tracked behavioral health service utilization among 146 Medicaid-eligible participants in the Pennsylvania ACCESS program. Utilization patterns of inpatient, outpatient, and emergency department services for psychiatric and substance abuse treatment were examined during the year prior to, during, and one year after the implementation of the ACCESS project. Use of psychiatric ambulatory care significantly increased among intervention participants and remained greater following ACCESS intervention. Better continuity of care following hospitalization was achieved during and after the intervention. The number of days spent hospitalized significantly decreased during the intervention. These results suggest that the ACCESS intervention was effective in linking hard-to-reach homeless persons with serious mental illness to the community mental health service system, and that this effect was maintained after termination of the intervention.

Psychiatric service utilization and cost for persons with schizophrenia in a Medicaid managed care program.

A pre-post study design was used to look at changes in behavioral health care services and costs for Medicaid-eligible individuals with schizophrenia in a managed care (MC) carve-out compared to a fee-for-service (FFS) program in Pennsylvania between 1995 and 1998. Statistically significant reductions of 59% were found in hospital expenditures in the MC program compared to 18.3% in the FFS program. The decline in hospital costs was due to dramatic fee reductions in the MC site. No significant differences in overall ambulatory utilization were found in either program; however, ambulatory expenditures rose 57% in the MC program versus a decline of 11% in fee for service. The ambulatory cost increase resulted from a cost shift between county block grant funds, and Medicaid funds, with no additional revenues provided to outpatient providers. Study implications are that cost reductions from MC are mainly due to reducing utilization and payments to hospitals, similar to the findings for private sector programs.

Trends in the rate and type of antipsychotic medications prescribed to persons with schizophrenia.

This article examines trends in antipsychotic medication use in a treated population of publicly funded patients with schizophrenia between 1991 and 1996. Findings from administrative claims data show that antipsychotic prescription rates increased from 79 percent to 83 percent between 1991 and 1996. Atypical antipsychotics were used by 39 percent of the population and comprised 41 percent of all antipsychotic agents prescribed compared to 59 percent for typical agents. Duration on a typical agent was 8 months versus 7.4 months for newer atypicals, with duration 11 months for those on clozapine. The highest switching behavior is found in users of atypicals (58% versus 25% for those on typicals) as is the percent of those who received an antidepressant concurrently with an antipsychotic, which was 44 percent for newer atypical users versus 31 percent for typical users. The lowest antidepressant use was among clozapine users (28%). Atypical users were more likely to be younger Caucasian men with higher use of inpatient and ambulatory mental health services compared to those on typical medications. The newer antipsychotic medications appear to be displacing traditional medications; however, contrary to what the literature suggests, duration is shorter and switching behavior and concurrent use of antidepressants is higher than in typical users.

Racial disparities in antipsychotic prescription patterns for patients with schizophrenia.

OBJECTIVE: This study aimed to examine the extent and type of variation in antipsychotic prescription patterns between African American and Caucasian patients with schizophrenia. METHOD: Subjects were 2,515 adult Medicaid recipients treated for schizophrenia in 1995 with one of four types of antipsychotic medication (traditional antipsychotics, clozapine, risperidone, or depot antipsychotics). Prescription and mental health service use data were collected from Medicaid claims files for the 12 months following the first filled antipsychotic prescription. Patterns of antipsychotic prescription were compared for African American (N=1,538, 61%) and Caucasian (N=977, 39%) subjects. RESULTS: African American subjects were significantly younger and more likely to receive Supplemental Security Income than were the Caucasian subjects, who received mental health services more continuously. African American subjects were less likely than Caucasian subjects to receive clozapine (8% versus 15%, respectively) and risperidone (25% versus 31%) and more likely to receive depot antipsychotics (26% versus 14%). The likelihood of receiving clozapine or risperidone remained significantly different after demographic and service use characteristics were controlled. CONCLUSIONS: This study found ethnic disparities in antipsychotic prescription patterns among a large number of publicly insured clients treated for schizophrenia. Given the rapidly changing pharmacological treatment environment, these findings have significant implications for differential quality of care for African American patients. Future studies employing client and provider characteristics are urgently needed to test alternative explanations for ethnic disparities.