Telehealth Utilization Among Adult Medicaid Beneficiaries in North Carolina with Behavioral Health Conditions During the COVID-19 Pandemic.

OBJECTIVE: We examined factors associated with telehealth utilization during COVID-19 among adult Medicaid beneficiaries with behavioral health conditions. DATA SOURCES AND STUDY SETTING: NC Medicaid 2019-2021 beneficiary and claims data. STUDY DESIGN: This retrospective cohort study examined and compared behavioral health service use pre-COVID-19 (03/01/2019 to 02/28/2020) and during COVID-19 (04/01/2020 to 03/31/2021). Telehealth users included those with at least one behavioral health visit via telehealth during COVID-19. Descriptive statistics were calculated for overall sample and by telehealth status. Multilevel modified Poisson generalized estimating equation examined associations between telehealth use and patient- and area-level characteristics. DATA COLLECTION/EXTRACTION METHODS: We identified individuals ages ≥ 21-64, diagnosed with a behavioral health condition, and had at least one behavioral-health specific visit before COVID-19. PRINCIPAL FINDINGS: Almost two-thirds of the cohort received behavioral health services during COVID-19, with half of these beneficiaries using telehealth. Non-telehealth users had steeper declines in service use from pre- to during COVID-19 compared to telehealth users. Beneficiaries identifying as Black, multiracial or other were significantly less likely to use telehealth (ARR = 0.86; 95% CI: (0.83, 0.89)); (ARR = 0.92; 95% CI: (0.87, 0.96)) compared to White beneficiaries. Those eligible for Medicaid through the blind/disabled programs and who qualified for a state-specific specialized behavioral health plan were more likely to use telehealth (17% and 20%, respectively). CONCLUSIONS: During the pandemic, telehealth facilitated continuity of care for beneficiaries with behavioral health conditions. Future research should aim to investigate how to reduce the digital divide and ensure equitable access to telehealth.

Racial and Ethnic Differences in Psychotropic Prescription Receipt Among Pediatric Patients Enrolled in North Carolina Medicaid.

OBJECTIVE: The authors aimed to examine racial-ethnic differences in filled psychotropic prescriptions among a pediatric Medicaid population. METHODS: This retrospective cohort study included patients ages 0-21 with at least one North Carolina Medicaid claim from October 1, 2017, through September 30, 2018 (N=983,886). The primary outcome was a filled psychotropic prescription. Separate multivariable modified Poisson regression models generated adjusted risk ratios (ARRs) and 95% confidence intervals (CIs), adjusted for patient demographic characteristics. RESULTS: Black and Hispanic patients were significantly less likely to receive any filled psychotropic prescription (ARR=0.61, 95% CI=0.60-0.62; ARR=0.29, 95% CI=0.28-0.29, respectively) compared with White and non-Hispanic patients. Furthermore, Black and Hispanic patients were less likely to receive filled prescriptions in the four included drug classes compared with White and non-Hispanic patients. CONCLUSIONS: Future studies should focus on understanding the factors contributing to racial and ethnic differences among pediatric patients receiving filled psychotropic prescriptions.

Use of North Carolina Medicaid Collaborative Care Billing Codes After Statewide Approval for Reimbursement.

Effective October 2018, North Carolina Medicaid approved reimbursement for collaborative care model (CoCM) billing codes. From October 2018 through December 2019, only 915 of the estimated two million eligible Medicaid beneficiaries had at least one CoCM claim, and the median number of claims per patient was two. Availability of reimbursement for CoCM Medicaid billing codes in North Carolina did not immediately result in robust utilization of CoCM. Furthermore, the low median number of claims per patient suggests lack of fidelity to CoCM. A better understanding of barriers to CoCM implementation is necessary to expand utilization of this evidence-based model.

Inequities in Receipt of the North Carolina Medicaid Waiver Among Individuals with Intellectual Disability or Autism Spectrum Disorder.

OBJECTIVE: We examined characteristics associated with receiving the North Carolina Home and Community-Based Services Waiver for intellectual and developmental disabilities (I/DDs) and its association with emergency department (ED) utilization. METHOD: Through analysis of the North Carolina 2017 to 2018 Medicaid claims and enrollment data, we examined characteristics (age, sex, race and ethnicity, geography, diagnosis (intellectual disability [ID] with or without autism spectrum disorders or autism spectrum disorder without ID) associated with receiving the NC I/DD Waiver and the association of this Wavier with ED utilization. We identified patients with at least 1 International Classification of Diseases-10-CM diagnosis code for an ID or autism spectrum disorder. We excluded patients with missing county information and whose enrollment in the NC I/DD Waiver program began after October 1, 2017. RESULTS: Only 22% of 53,531 individuals with I/DD in North Carolina received the Waiver. Non-Hispanic Blacks and Hispanic individuals were less likely to receive the Waiver than non-Hispanic White individuals. Adults (>21 years old), men, and urban residents were more likely to receive the Waiver. Individuals who received the Waiver were 31% less likely to use the ED. CONCLUSION: Innovative strategies are needed to provide equitable access to the NC I/DD Waiver and provide services to the 14,000 people with I/DD currently waiting to receive the Waiver. Through the Waiver, those with I/DD can access preventative and therapeutic outpatient services and decrease their need for ED care. These findings highlight the need for policy reform to address inequities in access to the Waiver for individuals with I/DD.

Seasonality of Pediatric Mental Health Emergency Department Visits, School, and COVID-19.

OBJECTIVES: The aim of this study was to explore how the academic calendar, and by extension school-year stressors, contributes to the seasonality of pediatric mental health emergency department (ED) visits. METHODS: The authors reviewed all pediatric mental health ED visits at a large urban medical center from 2014 to 2019. Patients who were younger than 18 years at time of presentation, were Durham residents, and had a primary payer of Medicaid were included in the sample population, and the dates of ED visits of the sample population were compared against dates of academic semesters and summer/winter breaks of a relevant school calendar. Of patients with multiple ED visits, only the first ED presentation was included, and descriptive statistics and a rate ratio were used to describe the study group and identify the rate of ED visits during semesters compared with breaks. RESULTS: Among the sample population from 2014 to 2019, there were 1004 first pediatric mental health ED visits. Of these ED visits, the average number of visits per week during summer/winter breaks was 2.2, and the average number of visits per week during academic semester dates was 3.4. The rate of ED visits was significantly greater during academic semesters compared with breaks (Rate Ratio, 1.6; 95% confidence interval, 1.4-2.0; P < 0.001). CONCLUSIONS: Children may be at greater risk of behavioral health crises or having increased mental needs when school is in session. As many children's mental health has worsened during the COVID-19 (coronavirus disease 2019) pandemic, these findings highlight the need for increased mental health services in the school setting as children return to in-person learning. In addition, it may benefit health systems to plan behavioral health staffing around academic calendars.

Clinical Application of a Peer Coaching Intervention to Enhance Self-Management for Adolescents and Young Adults With Inflammatory Bowel Disease.

Objective: The purpose of this article is to characterize the current evidence base related to peer support interventions for adolescents and young adults (AYAs) with inflammatory bowel disease (IBD) and to describe a peer support program to enhance self-management for AYAs with IBD through a case study. There is strong theory and compelling evidence suggesting that AYAs with IBD could benefit from and are interested in receiving peer support to enhance self-management; however, literature on peer support interventions for AYAs with IBD is lacking. Methods: This study (a) presents a topical review describing qualitative factors AYAs with IBD would seek in a peer support program as well as existing peer support programs for this population, (b) presents an innovative one-to-one peer support program targeting self-management through a case study, and (c) discusses clinical implications and directions for future research. Results: Peer support offers a promising approach for AYAs with IBD that is feasible and acceptable to patient populations. However, results from the present topical review identified only two studies that examined peer support interventions for AYAs with IBD. The case study demonstrates how a theoretically driven program uses peer support to promote self-management and adaptive behavioral change. Conclusions: The paucity of literature in this area reveals a critical opportunity for future research and clinical programming to improve existing practices by leveraging peer support. We present the application of an innovative mobile-based peer coaching intervention that has the potential to support AYAs with IBD in their self-management.

Identifying Individuals With Intellectual Disability Within a Population Study.

BACKGROUND: Much remains unknown about the longitudinal health and well-being of individuals with intellectual disability (ID); thus, new methods to identify those with ID within nationally representative population studies are critical for harnessing these data sets to generate new knowledge. OBJECTIVE: Our objective was to describe the development of a new method for identifying individuals with ID within large, population-level studies not targeted on ID. METHODS: We used a secondary analysis of the de-identified, restricted-use National Longitudinal Study of Adolescent to Adult Health (Add Health) database representing 20,745 adolescents to develop a method for identifying individuals who meet the criteria of ID. The three criteria of ID (intellectual functioning, adaptive functioning, and disability originating during the developmental period) were derived from the definitions of ID used by the American Psychiatric Association and the American Association on Intellectual and Developmental Disabilities. The ID Indicator was developed from the variables indicative of intellectual and adaptive functioning limitations included in the Add Health database from Waves I to III. RESULTS: This method identified 441 adolescents who met criteria of ID and had sampling weights. At Wave I, the mean age of this subsample of adolescents with ID was 16.1 years. About half of the adolescents were male and from minority racial groups. Their parents were predominately female, were married, had less than a high school education, and had a median age of 41.62 years. The adolescents' mean maximum abridged Peabody Picture Vocabulary Test standardized score was 69.6, and all demonstrated at least one adaptive functioning limitation. DISCUSSION: This study demonstrates the development of a data-driven method to identify individuals with ID using commonly available data elements in nationally representative population data sets. By utilizing this method, researchers can leverage existing rich data sets holding potential for answering research questions, guiding policy, and informing interventions to improve the health of the ID population.

Health Care Transition for Adolescent and Young Adults with Intellectual Disability: Views from the Parents.

PURPOSE: This study explored the health care transition (HCT) experiences of parents of adolescents and young adults (AYAs) with intellectual disability (ID), 18-33 years of age, including barriers and facilitators to the AYA's transition to adulthood within and between the medical, educational, community, and vocational systems. DESIGN AND METHODS: A qualitative descriptive design with semi-structured individual interviews with 16 parent participants was used. Purposive sampling of parents was utilized with variation on race/ethnicity and AYA age, stage in transition, and condition. This study was conducted through a major medical center in the southeast United States. Content analysis was utilized. RESULTS: Three overarching themes represented the factors and essence of supporting AYAs with ID transition to adulthood. Inefficient and siloed systems illuminated barriers families are commonly experiencing within and between the medical, educational, community, and vocational systems. 'Left out here floundering' in adulthood, described the continued inadequacy of resources within each of these systems and parent's having to find available resources themselves. Hope despite uncertainty, included the perceived costs and benefits of their AYA's disability and the value of parent peer support in providing key knowledge of resources, strategies, and perspectives. CONCLUSIONS: Our findings illuminate the need for improved infrastructure to provide effective HCT and partnerships to help integrate HCT support within other life course systems. Results support the rationale for non-categorical HCT-focused approach. PRACTICE IMPLICATIONS: A parent peer coach-facilitated intervention offers promise for bridging the gap between systems and meeting family needs.

Where Did They Go? Tracking Young Adult Follow-up During the Transition From Pediatric to Adult-Oriented Care.

Continuity of care during health care transition is critical. We sought to evaluate electronic medical record clinic attendance data to examine this outcome. We identified 1623 patients (ages 18-27 years) with 1 of 6 childhood-onset chronic conditions and tracked clinic utilization from January 2002 to July 2016. Patients were classified as active in pediatric care; lost from pediatric care; successfully transferred; or lost from adult care. Using random effects logistic regression, we compared the number of days between last pediatric and first adult visit to each clinic's self-reported transitional care quality score. In this cohort, >44% remained active in care at the end of the study. Clinics with higher proportions of successfully transferred patients had lower median numbers of days between last pediatric and first adult visit and higher transitional care quality scores. Characterizing utilization patterns with electronic medical record data allows health systems to track transitional care outcomes and target improvement efforts.

Lost in transition: resident and fellow training and experience caring for young adults with chronic conditions in a large United States' academic medical center.

BACKGROUND: The transition from pediatric to adult healthcare is a vulnerable time for adolescents and young adults (AYA), especially those with chronic conditions. Successful transition requires communication and coordination amongst providers, patients, and families. Unfortunately, multiple studies have demonstrated that the majority of practicing providers do not feel prepared to help AYA patients through health care transition, but little is known about the transition/transfer aptitudes of physician trainees. OBJECTIVES: The purpose of this study was to establish the transition/transfer training that residents and fellows from different fields receive - and determine what training factors are associated with increased confidence in core transition/transfer skills. DESIGN: A 20-item electronic survey regarding experiences caring for AYA patients was sent to all 2014-2015 graduate medical education (GME) trainees at our institution. RESULTS: Forty-nine percent (479/985) of trainees responded: 60 pediatric, 387 non-pediatric, and 32 'combined' (e.g., Medicine/Pediatrics or Family Medicine). Trainees from all three categories of programs reported similar exposure to AYA patients with chronic conditions, with a median of 1-3 encounters per month. A quarter of trainees rated themselves as 'not at all prepared' to speak with a counterpart provider about a transferring patient, while nearly half of trainees considered themselves 'not at all prepared' to speak with a patient and family about transition. Trainee confidence in performing these two skills was strongly predicted by three factors: increased exposure to AYA with chronic conditions, education (training or role modeling) in transition skills, and experience practicing transition skills. Of these, the strongest association with trainee confidence was experience practicing the skills of communicating with other providers (OR = 13.0) or with patients/families (OR = 14.5). CONCLUSION: Despite at least monthly encounters with AYA with chronic conditions, most residents and fellows have very little experience communicating across the pediatric-to-adult healthcare divide, highlighting training opportunities in graduate medical education.

Feeling and body investigators (FBI): ARFID division-An acceptance-based interoceptive exposure treatment for children with ARFID.

OBJECTIVE: Individuals with Avoidant Restrictive Food Intake Disorder (ARFID) experience impairing health consequences from insufficient nutritional variety and/or quantity. Early medical conditions and/or somatic symptoms such as abdominal pain may lead some with ARFID to experience somatic sensations as aversive. As such, food avoidance may be part of a broader behavioral repertoire aimed at suppressing bodily sensations. Avoiding these necessary and informative signals (e.g., growls of hunger) may subvert the emergence of healthy self-awareness and self-regulation. Teaching children with ARFID to engage adaptively with bodily sensations may help decrease aversiveness, increase self-awareness, and increase approach behaviors. METHOD: Drawing from interventions for panic disorder and irritable bowel syndrome, we developed an acceptance-based interoceptive exposure treatment for young children with ARFID, Feeling and Body Investigators (FBI)-ARFID Division. Using playful cartoons and developmentally sensitive exposures, we teach young children how to map interoceptive sensations onto meanings (e.g., emotions) and actions (e.g., if I feel nervous, I'll hold someone's hand). RESULTS: We present a case study of a 4-year old child with lifelong poor appetite/food indifference. DISCUSSION: Some individuals with ARFID may avoid food to avoid internal sensations. Developmentally appropriate interoceptive exposures may decrease ARFID symptoms while increasing more general self-regulation skills.

Nonpharmacologic Treatments for Attention-Deficit/Hyperactivity Disorder: A Systematic Review.

CONTEXT: Nonpharmacologic treatments for attention-deficit/hyperactivity disorder (ADHD) encompass a range of care approaches from structured behavioral interventions to complementary medicines. OBJECTIVES: To assess the comparative effectiveness of nonpharmacologic treatments for ADHD among individuals 17 years of age and younger. DATA SOURCES: PubMed, Embase, PsycINFO, and Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2009 through November 7, 2016. STUDY SELECTION: We included studies that compared any ADHD nonpharmacologic treatment strategy with placebo, pharmacologic, or another nonpharmacologic treatment. DATA EXTRACTION: Study design, patient characteristics, intervention approaches, follow-up times, and outcomes were abstracted. For comparisons with at least 3 similar studies, random-effects meta-analysis was used to generate pooled estimates. RESULTS: We identified 54 studies of nonpharmacologic treatments, including neurofeedback, cognitive training, cognitive behavioral therapy, child or parent training, dietary omega fatty acid supplementation, and herbal and/or dietary approaches. No new guidance was identified regarding the comparative effectiveness of nonpharmacologic treatments. Pooled results for omega fatty acids found no significant effects for parent rating of ADHD total symptoms (n = 411; standardized mean difference -0.32; 95% confidence interval -0.80 to 0.15; I2 = 52.4%; P = .10) or teacher-rated total ADHD symptoms (n = 287; standardized mean difference -0.08; 95% confidence interval -0.47 to 0.32; I2 = 0.0%; P = .56). LIMITATIONS: Studies often did not reflect the primary care setting and had short follow-up periods, small sample sizes, variations in outcomes, and inconsistent reporting of comparative statistical analyses. CONCLUSIONS: Despite wide use, there are significant gaps in knowledge regarding the effectiveness of ADHD nonpharmacologic treatments.

Preliminary Outcomes from an Integrated Pediatric Mental Health Outpatient Clinic.

An estimated 1 in 5 children in the United States meet criteria for a diagnosable mental disorder, yet fewer than 20% receive mental health services. Unmet need for psychiatric treatment may contribute to patterns of increasing use of the emergency department. This article describes an integrated pediatric evaluation center designed to prevent the need for treatment in emergency settings by increasing access to timely and appropriate care for emergent and critical mental health needs. Preliminary results showed that the center provided rapid access to assessment and treatment services for children and adolescents presenting with a wide range of psychiatric concerns.

Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews.

OBJECTIVES: Examine Peer Support (PS) for complex, sustained health behaviors in prevention or disease management with emphasis on diabetes prevention and management. DATA SOURCES AND ELIGIBILITY: PS was defined as emotional, motivational and practical assistance provided by nonprofessionals for complex health behaviors. Initial review examined 65 studies drawn from 1442 abstracts identified through PubMed, published 1/1/2000-7/15/2011. From this search, 24 reviews were also identified. Extension of the search in diabetes identified 30 studies published 1/1/2000-12/31/2015. RESULTS: In initial review, 54 of all 65 studies (83.1%) reported significant impacts of PS, 40 (61.5%) reporting between-group differences and another 14 (21.5%) reporting significant within-group changes. Across 19 of 24 reviews providing quantifiable findings, a median of 64.5% of studies reviewed reported significant effects of PS. In extended review of diabetes, 26 of all 30 studies (86.7%) reported significant impacts of PS, 17 (56.7%) reporting between-group differences and another nine (30.0%) reporting significant within-group changes. Among 19 of these 30 reporting HbA1c data, average reduction was 0.76 points. Studies that did not find effects of PS included other sources of support, implementation or methodological problems, lack of acceptance of interventions, poor fit to recipient needs, and possible harm of unmoderated PS. CONCLUSIONS: Across diverse settings, including under-resourced countries and health care systems, PS is effective in improving complex health behaviors in disease prevention and management including in diabetes.

Resident Dyads Providing Transition Care to Adolescents and Young Adults With Chronic Illnesses and Neurodevelopmental Disabilities.

BACKGROUND: Youth with special health care needs often experience difficulty transitioning from pediatric to adult care. These difficulties may derive in part from lack of physician training in transition care and the challenges health care providers experience establishing interdisciplinary partnerships to support these patients. OBJECTIVE: This educational innovation sought to improve pediatrics and adult medicine residents' interdisciplinary communication and collaboration. METHODS: Residents from pediatrics, medicine-pediatrics, and internal medicine training programs participated in a transitions clinic for patients with chronic health conditions aged 16 to 26 years. Residents attended 1 to 4 half-day clinic sessions during 1-month ambulatory rotations. Pediatrics/adult medicine resident dyads collaboratively performed psychosocial and medical transition consultations that addressed health care navigation, self-care, and education and vocation topics. Two to 3 attending physicians supervised each clinic session (4 hours) while concurrently seeing patients. Residents completed a preclinic survey about baseline attitudes and experiences, and a postclinic survey about their transitions clinic experiences, changes in attitudes, and transition care preparedness. RESULTS: A total of 46 residents (100% of those eligible) participated in the clinic and completed the preclinic survey, and 25 (54%) completed the postclinic survey. A majority of respondents to the postclinic survey reported positive experiences. Residents in both pediatrics and internal medicine programs reported improved preparedness for providing transition care to patients with chronic health conditions and communicating effectively with colleagues in other disciplines. CONCLUSIONS: A dyadic model of collaborative transition care training was positively received and yielded improvements in immediate self-assessed transition care preparedness.

Receipt of Recommended Adolescent Vaccines Among Youth With Special Health Care Needs.

We examined vaccination coverage among youth with special health care needs (YSHCN) using data from parents of adolescents (11-17 years) who responded to a statewide survey in 2010-2012 (n = 2156). Using a validated screening tool, we identified 29% of adolescents as YSHCN. Weighted multivariable logistic regression assessed associations between special health care needs and receipt of tetanus booster, meningococcal, and human papillomavirus (HPV) vaccines. Only 12% of youth had received all 3 vaccines, with greater coverage for individual vaccines (tetanus booster, 91%; meningococcal, 32%; HPV, 26%). YSHCN had greater odds of HPV vaccination than other youth (33% vs 23%, OR = 1.70, 95% CI = 1.16-2.50) but vaccination coverage was similar ( P ≥ .05) for other outcomes. In subgroup analyses, HPV vaccination also differed depending on the number and type of special health care needs identified. Findings highlight low levels of vaccination overall and missed opportunities to administer recommended vaccines among all youth, including YSHCN.