Scaling a Behavioral Health Home Delivery Model to Special Populations.

The present project utilized a Learning Collaborative (LC) to disseminate the Behavioral Health Home Plus (BHHP) physical-behavioral health integration model to providers serving two behavioral health populations at risk for adverse health conditions: youth psychiatric residential treatment facilities (five sites) and adult opioid treatment providers (seven sites). Following the positive results of a randomized controlled trial utilizing an LC to implement two behavioral health home models in community mental health provider organizations serving adults with serious mental illness, Community Care Behavioral Health Organization facilitated integration of the models to scale health and wellness supports to additional behavioral health care delivery settings. This paper presents provider results focused on BHHP implementation training, LC implementation, physical health and wellness promotion within sites, and BHHP model sustainment plans. Provider self-reported data indicate that the LC approach is a successful tool for integrating and sustaining BHHP model components in routine care.

Association of Counseling and Psychotherapy on Retention in Medication for Addiction Treatment Within a Large Medicaid Population.

OBJECTIVES: Buprenorphine/naloxone is an effective medication for the treatment of opioid use disorder. Unlike methadone, which can only be dispensed in federally waived clinics and which must be combined with specific psychosocial treatment, buprenorphine can be dispensed by individual prescribers who have completed an 8-hour training program, with no requirement that patients receive concomitant psychotherapy. The objective of this study is to quantify the association of counseling and psychotherapy on retention in treatment. We also examine the effect of buprenorphine dosage on retention. METHODS: We examined a cohort of 4987 members of a not-for-profit managed care organization serving Medicaid members in 41 counties in Pennsylvania. This cohort was selected from all members who had a full year without any medication for opioid use disorder followed by initiation of treatment with buprenorphine/naloxone in 2016 to 2017 and who remained Medicaid eligible for at least 80% of the following 2 years. Outcomes were estimated using inverse probability weighted propensity scores. RESULTS: The addition of counseling and psychotherapy within the first 8 weeks of treatment was associated with greater total retention in treatment and there was a dose-response relationship. A 16 mg/d or greater dose of buprenorphine was also associated with greater retention. CONCLUSIONS: These results provide support for an integrated approach to treating people with an opioid use disorder, through a combination of buprenorphine pharmacotherapy and targeted counseling and psychotherapy within the first 2 months of treatment.

Prioritized Research for the Prevention, Treatment, and Reversal of Chronic Disease: Recommendations From the Lifestyle Medicine Research Summit.

Declining life expectancy and increasing all-cause mortality in the United States have been associated with unhealthy behaviors, socioecological factors, and preventable disease. A growing body of basic science, clinical research, and population health evidence points to the benefits of healthy behaviors, environments and policies to maintain health and prevent, treat, and reverse the root causes of common chronic diseases. Similarly, innovations in research methodologies, standards of evidence, emergence of unique study cohorts, and breakthroughs in data analytics and modeling create new possibilities for producing biomedical knowledge and clinical translation. To understand these advances and inform future directions research, The Lifestyle Medicine Research Summit was convened at the University of Pittsburgh on December 4-5, 2019. The Summit's goal was to review current status and define research priorities in the six core areas of lifestyle medicine: plant-predominant nutrition, physical activity, sleep, stress, addictive behaviors, and positive psychology/social connection. Forty invited subject matter experts (1) reviewed existing knowledge and gaps relating lifestyle behaviors to common chronic diseases, such as cardiovascular disease, diabetes, many cancers, inflammatory- and immune-related disorders and other conditions; and (2) discussed the potential for applying cutting-edge molecular, cellular, epigenetic and emerging science knowledge and computational methodologies, research designs, and study cohorts to accelerate clinical applications across all six domains of lifestyle medicine. Notably, federal health agencies, such as the Department of Defense and Veterans Administration have begun to adopt "whole-person health and performance" models that address these lifestyle and environmental root causes of chronic disease and associated morbidity, mortality, and cost. Recommendations strongly support leveraging emerging research methodologies, systems biology, and computational modeling in order to accelerate effective clinical and population solutions to improve health and reduce societal costs. New and alternative hierarchies of evidence are also be needed in order to assess the quality of evidence and develop evidence-based guidelines on lifestyle medicine. Children and underserved populations were identified as prioritized groups to study. The COVID-19 pandemic, which disproportionately impacts people with chronic diseases that are amenable to effective lifestyle medicine interventions, makes the Summit's findings and recommendations for future research particularly timely and relevant.

A comparison of adherence, outcomes, and costs among opioid use disorder Medicaid patients treated with buprenorphine and methadone: A view from the payer perspective.

Medication-assisted treatment (MAT) with methadone or buprenorphine has been shown to be more effective at reducing the use of illicit opioids, the risk of drug-related overdose, and overall healthcare costs, on average, compared to abstinence-based addiction treatments for individuals with an opioid use disorder (OUD). Individuals who are adherent to MAT are more likely to experience positive outcomes. We used physical and behavioral Medicaid claims data of individuals newly treated with methadone (n = 212) and buprenorphine (n = 972) to examine the overall predictors of adherence, differences in adherence to each medication, the relationship between adherence and ED nonfatal drug-related overdose, and differences in total cost of care between the two medications. We found that older individuals and women had significantly lower risk of non-adherence. At six months, only 3.6% of individuals who were adherent to either treatment experienced a nonfatal drug-related overdose in the ED, compared to 13.2% of individuals who were non-adherent. We found no significant difference between methadone and buprenorphine on nonfatal drug-related overdose. Non-adherence to methadone was associated with a significant increase in total cost of care. Implications for how these results could be used to improve the overall impact of MAT are discussed.

Care Management Intervention to Decrease Psychiatric and Substance Use Disorder Readmissions in Medicaid-Enrolled Adults.

This study examines the generalizability of a successful care management bridging strategy implemented by a behavioral health managed care organization to reduce readmission in psychiatric and substance use disorder (SUD) populations. The sample included 1724 individuals with a psychiatric or SUD hospitalization or detoxification service within 30-days of a prior SUD or inpatient event; 1243 Medicaid-enrolled adults received the intervention plus usual care, and 481 individuals received only usual care. Results included lower readmission to SUD facilities (p = .0012) and reduced odds of readmission among individuals with a SUD event (OR = 0.49, p = .0006) for the intervention versus the comparison group. Likelihood of readmission was higher for those with dual diagnoses (OR = 1.72, p = .0002) or in urban settings (OR = 1.47, p = .0010), with some evidence of the intervention's success in these populations. Care management bridging strategies may be more effective for individuals who utilize SUD services and others who need help navigating complex systems of care.

Reducing Problematic Benzodiazepine Use Among Individuals Enrolled in Methadone Treatment Programs.

OBJECTIVE: The purpose of this study was to decrease problematic benzodiazepine (BZD) prescriptions provided to patients enrolled in methadone maintenance treatment (MMT) programs in an urban setting through a quality improvement intervention. METHODS: A prospective, interactive, feedback loop was used with 4 MMT providers over a period of 5 years (2009-2013) to help reduce the number of BZD prescriptions that clients were receiving from other providers. To track individuals who were receiving a BZD prescription from an outside provider, MMT medical teams were provided with patient-level Medicaid pharmacy claims data every month for 5 years. A technical assistance team, comprised of a medical director, pharmacists, data analysts, clinical, and management information staff at a behavioral health managed care organization experienced in MMT, met with each of the 4 MMT providers at several time points to devise methods of reducing problematic BZD prescriptions and engaging community medical providers. RESULTS: A total of 3464 Medicaid eligible adults were included in the quality improvement project over the 5-year period. The overall rate of BZD prescriptions provided to patients decreased significantly, from 37% at the beginning of 2009, to 27% at the end of 2013. Three out of the 4 MMT programs showed a significant decrease in BZD prescriptions among their participants. CONCLUSIONS: The 4 MMT providers involved in the study found the ongoing feedback loops valuable in the process of managing the health risks of their MMT patients.

Examining attrition rates at one specialty addiction treatment provider in the United States: a case study using a retrospective chart review.

BACKGROUND: Engaging individuals who have a substance use disorder (SUD) in treatment continues to be a challenge for the specialty addiction treatment field. Research has consistently revealed high rates of missed appointments at each step of the enrollment process: 1. between calling for services and assessment, 2. between assessment and enrollment, and 3. between enrollment and completion of treatment. Extensive research has examined each step of the process; however, there is limited research examining the overall attrition rate across all steps. METHODS: A single case study of a specialty addiction treatment agency was used to examine the attrition rates across the first three steps of the enrollment process. Attrition rates were tracked between August 1, 2011 and July 31, 2012. The cohort included 1822 unique individuals who made an initial request for addiction treatment services. Monthly retrospective reviews of medical records, phone logs, and billing data were used to calculate attrition rates. Attrition rates reported in the literature were collected and compared to the rates found at the target agency. RESULTS: Median time between request for treatment and assessment was 6 days (mean 7.5) and between assessment and treatment enrollment was 8 days (mean 12.5). An overall attrition rate of 80% was observed, including 45% between call and assessment, 32% between assessment and treatment enrollment (another 17% could not be determined), and 37% left or were removed from treatment before 30 days. Women were less likely to complete 30 days of treatment compared to men. No other demographics were related to attrition rates. DISCUSSION: One out of every five people who requested treatment completed a minimum of 30 days of a treatment. The attrition rate was high, yet similar to rates noted in the literature. Limitations of the single case study are noted. CONCLUSION: Attrition rates in the U.S. are high with approximately 75% to 80% of treatment seekers disengaging at one of the multiple stages of the enrollment and treatment process. Significant changes in the system are needed to improve engagement rates.

Intensive case management as a jail diversion program for people with a serious mental illness: a review of the literature.

This article reviews the research on intensive case management (ICM) programs as a jail diversion intervention for people with a serious mental illness (SMI). The review includes two types of ICM programs: (a) general ICM programs that included an assessment of arrests and incarceration rates for people with an SMI and (b) ICM programs specifically implemented as a component of a jail diversion intervention for people with an SMI. Results indicate that general ICM programs (19) rarely led to reductions in jail or arrest rates over time, and these rates were similar to those found in standard mental health services. General ICM programs that included an integrated addiction treatment component (8) had mixed results but a trend toward reductions in rates of arrests and incarceration over time for individuals with an SMI and a co-occurring substance use disorder. Results were mixed for jail diversion interventions with an ICM program, but most ICM programs (8) led to significant reductions in arrests and incarcerations over time. Specific elements of effective ICM jail diversion programs are discussed.

What happens to patients' psychotropic prescriptions after discharge from a state psychiatric hospital?

Continuity of pharmacotherapy was examined between a state psychiatric hospital and an urban community mental health center. Anecdotal reports from administrators as well as limited empirical research suggested that there would be breaks in the continuity of pharmacotherapy across the two agencies and that the high cost of newer medications would contribute to poor continuity. Clinical chart reviews of 242 discharges over a 5-year period revealed that less than 11% of atypical prescriptions and less than 20% of all psychotropic prescriptions were altered beyond dosage level changes after discharge from a state hospital. Analysis of reasons given (reported) for altering the medication regimen revealed a consistent pattern of changes based on clinical evidence or consumer choice.