Behavioral Health Screening among Massachusetts Children Receiving Medicaid.

OBJECTIVE: To assess the impact of a Massachusetts Medicaid policy change (the Children's Behavioral Health Initiative; CBHI, which required and reimbursed behavioral health [BH] screening with standardized tools at well child visits and developed intensive home- and community-based BH services) on primary care practice examining the relationship of BH screening to subsequent BH service utilization. STUDY DESIGN: Using a repeated cross-sectional design, our 2010 and 2012 Medicaid study populations each included 2000 children/adolescents under the age of 21 years. For each year, the population was randomly selected and stratified into 4 age groups, with 500 members selected per group. Two data sources were used: medical records and Medicaid claims. RESULTS: The CBHI had a large impact on formal BH screening and treatment utilization among children/adolescents enrolled in Medicaid. Screening increased substantially (73%: 2010; 74%: 2012) since the baseline/premandate period (2007) when only 4% of well child visits included a formal screen. BH utilization increased among those formally screened but decreased among those with informal assessments. CONCLUSIONS: CBHI implementation transformed the relationship between primary care and BH services. Changes in regulation and payment resulted in widespread BH screening in Massachusetts primary care practices caring for children/adolescents on Medicaid.

The effect of a telephone-based health coaching disease management program on Medicaid members with chronic conditions.

BACKGROUND: Despite the growing popularity of disease management programs for chronic conditions, evidence regarding the effect of these programs has been mixed. In addition, few peer-reviewed studies have examined the effect of these programs on publicly insured populations. OBJECTIVES: To examine the effect of a telephone-based health coaching disease management program on healthcare utilization and expenditures in Medicaid members with chronic conditions. RESEARCH DESIGN: Using a difference-in-differences analysis, we examined changes in hospitalizations, emergency department (ED) visits, ambulatory care visits, and Medicaid expenditures among program members for 1 year before and 2 years after their enrollment compared with a matched comparison group. SUBJECTS: Medicaid members aged 18 to 64 with a diagnosis of qualifying chronic conditions and 2 acute health service events of hospitalizations and/or ED visits within a 12-month period. RESULTS: Changes in acute hospitalizations, ambulatory care visits, and Medicaid expenditures before and after program enrollment were similar between the 2 study groups. However, during the second year after enrollment, program members had a significantly smaller decrease in ED visits than the comparisons (8% in program members and 23% in comparisons, P value=0.03). CONCLUSIONS: Compared with a matched comparison group, the telephone-based health coaching disease management program did not demonstrate significant effects on healthcare utilization and expenditures in Medicaid members with chronic conditions.

Predictors of prenatal and postpartum care adequacy in a medicaid managed care population.

PURPOSE: To examine factors affecting prenatal and postpartum care for an insured, but vulnerable, population. METHODS: Individual-level data on three measures of care adequacy were obtained for Massachusetts Medicaid Managed Care women who met the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set denominator criteria for the prenatal and postpartum care measures in 2007 (n = 1,882). We modeled individual compliance with each measure separately as a binomial logistic function with individual and neighborhood characteristics, provider type, and health plan as explanatory variables. FINDINGS: In our sample, 85% of women initiated care in the first trimester, but only 62% met the goal of receiving more than 80% of the recommended number of prenatal visits. Just 60% had a timely postpartum care visit. Having a diagnosis of substance abuse or dependence reduced the odds of meeting all measures. Women with disabilities were less likely to attain two of the three measures of adequate care, as were women with other children in the household. Women who enrolled in Medicaid in the first trimester were more likely to receive the recommended number of prenatal visits than those who were enrolled before pregnancy. CONCLUSION: Given the importance of prenatal and postpartum care for maternal and child health and the recent national declining trend in timely care, initiatives to improve rates of timely and adequate care are crucial and must include components tailored toward particularly vulnerable subpopulations.

Disparities in routine breast cancer screening for Medicaid managed care members with a work-limiting disability.

OBJECTIVE: Examine disparities in routine mammography for women who qualify for Medicaid, because of a work-limiting disability. METHODS: Individual-level data were obtained for women enrolled in Massachusetts Medicaid Managed Care plans who met the 2007 Healthcare Effectiveness Data and Information Set (HEDIS) criteria for the breast cancer screening measure (n=35,171). Disability status was determined from Medicaid eligibility records. Mammography screening was modeled using multivariate logistic regression. Separate models for women with and without a disability were also estimated. RESULTS: Although unadjusted breast cancer screening rates were roughly equal for women with and without disability, after adjusting for confounders disability status had a significant negative association with screening mammography (OR=0.74; p<0.0001). Living farther from a mammography facility or having a diagnosis of domestic violence reduced the odds of screening for women with disabilities, but not for other women. Having a higher illness burden was more detrimental to screening for women with a disability than for those without. Both groups benefited similarly from the first 26 ambulatory care visits, but the impact of additional visits on screening was much larger among women with disabilities. CONCLUSION: Nationwide, rates of routine mammography for Medicaid managed care plans averaged below 50% in 2006. Given that a majority of eligible women served by Medicaid have disabilities, and studies have shown that women with disabilities are more likely to be diagnosed with late stage disease, a focus on improving rates of screening for women with disabilities is overdue.

Perceived changes in health and safety following participation in a health care-based domestic violence program.

This descriptive study explores perceived changes in health and safety and the potential process by which these changes occur. Forty-nine women experiencing intimate partner abuse participated in a health care-based domestic violence (DV) advocacy program for 6 months or more. An analysis of structured interviews in English and Spanish found that the majority of participants perceived positive changes in their personal safety and emotional health because of their involvement in the program. Some participants also perceived improvements in their physical health, unhealthy coping behaviors (e.g., overeating and smoking), and health care following program involvement. Participants' responses suggest a process of change whereby DV advocacy services first contribute to improved safety and emotional health, which then facilitates behavioral changes. Behavioral changes may subsequently contribute to improvements in physical health, which may also benefit emotional health. Longitudinal evaluations are needed to evaluate the impact of DV advocacy and other interventions for partner abuse on women's health and safety over time.

Impact of partner abuse on women's reproductive lives.

OBJECTIVE: To increase our understanding of how intimate partner abuse may limit women's reproductive choices. METHODS: Findings were obtained from a larger study involving interviews with 38 women participating in a hospital-based domestic violence program. We asked participants whether and in what ways their abusive partners had limited their ability to choose whether or not to have children. Content analysis was used to identify main themes. RESULTS: Thirteen (34%) participants reported that partners had limited their ability to choose whether or not to have children. Seven of these women described tactics to try to get them to have children, and 7 reported being pressured or forced to have abortions (1 woman reported both). Two women underwent sterilization in response to the abuse. Four of the 13 women reported contradictory behaviors by their partners around family planning, such as not allowing birth control, then demanding that the participant terminate the pregnancy. CONCLUSION: Women described several ways in which their abusive partners controlled or attempted to control their reproductive lives that have received little or no prior attention. Further studies are needed to determine the prevalence and consequences of these behaviors, particularly the extent to which women in abusive relationships feel coerced into sterilization or abortion.

The older nurse in the workplace: does age matter?

Between 2010 and 2020, over 40% of the RN workforce will be over 50 years of age, and many RNs are expected to retire and withdraw from the workforce. Given that older nurses are the fastest growing cohort of the workforce, the important findings presented in this article deserve careful consideration by policymakers, health care leaders, and managers.