Community Care Publications
Community Care Publication Abstracts
Care Management Intervention to Address Determinants of Health for Individuals with Multiple Behavioral Health Readmission
Purpose of Study: To examine the effectiveness of a care management intervention to decrease readmissions and to better understand clinical and social determinants associated with readmission. Primary Practice Setting: Inpatient mental health (MH) and substance use disorder (SUD) facilities, nonhospital SUD withdrawal management and rehabilitation facilities. Methodology and Sample: The authors identified 3,950 Medicaid-enrolled individuals who received the intervention from licensed clinical staff of a behavioral health managed care organization; 2,182 individuals were eligible but did not receive the intervention, for treatment as usual (TAU). We used logistic regression to examine factors associated with readmission. Determinants of readmission were summarized through descriptive tests. Results: The intervention was associated with lower readmissions to SUD facilities compared with TAU (6.0% vs. 8.6%, p = .0002) and better follow-up to aftercare. Controlling for clinical differences between groups, regression results found increased odds of readmission for male gender (odds ratio [OR]: 1.33; 95% confidence interval [CI]: 1.16–1.52, p < .0001) and dual MH and SUD diagnoses (OR: 1.52; CI: 1.29–1.79, p < .0001). Prior inpatient and case management services were also associated with increased odds for readmission. In the regression model, the intervention was not associated with decreased odds for readmission. Individuals with readmission (n = 796) were more likely to report being prescribed psychotropic medication and having housing difficulties and less likely to report having a recovery plan than those without readmission. Implications for Case Management Practice: Characteristics of Medicaid populations with hospitalization may contribute to readmission, which may be mitigated through care management intervention.
Peer support to reduce readmission in Medicaid-enrolled adults with substance use disorders
Introduction: Peer support service in substance use disorder systems (PS SUD) is an optional supplement to treatment services for Medicaid-enrolled individuals across Pennsylvania. The value of PS SUD was defined through association with improved service utilization patterns. We examined service utilization in a subset of individuals receiving PS SUD following an acute service (hospitalization or withdrawal management) compared to utilization in propensity-score-matched controls via an observational analysis. Methods: We identified all Medicaid-enrolled adults with receipt of PS SUD from 2016 to 2019 and included those with prior acute service (n = 349); the study successfully matched all to individuals receiving outpatient SUD services without peer support (n = 698). Individuals were matched on age, gender, race, ethnicity, diagnosis, and prior utilization of acute care. A large percentage of individuals receiving PS SUD (74 %) had co-occurring mental health diagnoses, which we included in matching. We examined service utilization rates via administrative paid claims data for both groups in the first 90 days following peer support/outpatient discharge. Results: Acute service utilization differed between groups over time, p = .0014. We observed a larger reduction in the rate of acute care during PS SUD service (8.6 %) versus outpatient service (21.2 %), with lower rates remaining 90 days following PS SUD (13.8 %) or outpatient discharge (16.8 %). Individuals receiving PS SUD showed connection to community-based services in the 90 days following discharge from PS SUD, including 45.0 % receiving outpatient SUD and 31.8 % receiving outpatient mental health services. Conclusions: Peer support may help individuals to navigate the behavioral health system and reduce hospitalization or other restrictive levels of care.
Implementing a trauma-informed system of care: An analysis of learning collaborative outcomes
Trauma exposure can negatively impact health. Trauma-informed care implementation within health care systems may improve the identification and treatment of trauma-related illness on a population health level. The current study investigated outcomes of a multiagency implementation of trauma-informed care for Medicaid-enrolled adults and children in 23 rural Pennsylvania (United States) counties. Changes in trauma symptom screening, the number of staff trained in trauma-informed care, and clinician confidence in using trauma-informed care were assessed in participating treatment agencies (N = 22) over the course of a 15-month trauma-informed care learning collaborative (TLC). Data included monthly agency-reported screening, training, and confidence outcomes, which were analyzed using repeated-measures analyses of variance. Trauma symptom screening rates improved from 41.1% (SD = 43.0%) to 93.3% (SD = 12.0), p < .001; ηp2 = .30. The average number of cumulative staff members trained in trauma-informed care per agency increased from 24.43 (SD = 42.22) to 140.00 (SD = 150.87), p < .001, Kendall’s W = .09. The percentage of agencies that reported high confidence in delivering trauma-informed care increased from 15.8% (SD = 15.5%) to 80.5% (SD = 17.7%), p < .001; ηp2 = .45. Pairwise comparisons revealed both screening rates and confidence ratings reached significant improvement in Month 11 of the TLC, suggesting that these processes may be related. A total of 2,935 staff members were trained during the TLC. The immediate impact of system-level implementation of trauma-informed care was evident for agency processes and staff confidence, with support provided by multiple stakeholders.
Lessons learned implementing a trauma-informed system of care in rural communities
Background: The negative impact of trauma on health is devastating. Providers, especially those in rural areas, require support to implement trauma-informed care (TIC) on a systems level.
Objectives: This paper describes a partnership of county behavioral health administrators, service providers, and a behavioral health managed care organization and steps taken over a 5-year initiative to enhance capacity and quality of community services to meet the needs of individuals in a rural setting to receive TIC.
Methods: The initiative included trainings in evidence-based and best practices in TIC, improved trauma screening, development of TIC centers, and development of community-based networks for ongoing support. Lessons learned were summarized through discussions between partnership members.
Lessons Learned: Shared ownership, opportunity to build networks, and continuous assessment of organizational strengths resulted in successful implementation and sustained practice. Challenges included turnover among staff and organizations.
Conclusions: Building a TIC network across a rural healthcare system can be successful with long-term support and investment from multiple stakeholders.
Implementing trauma‑informed care through a Learning Collaborative: A theory‑driven analysis of sustainability
This study investigated the sustainability of a multi-agency 15-month Learning Collaborative (LC) for implementing trauma-informed care in 23 rural Pennsylvania counties. Provider agencies (N = 22) were assessed three years following completion of the LC. Sustained trauma-informed practices were assessed through criteria indicating organizational achievement as a trauma-informed care center. A theoretical model of clinical training was applied to determine the extent to which training and skill-related factors were associated with sustained trauma-informed care. Three years after the LC, trauma symptom screening rates and staff training improvements were sustained, while staff confidence in delivering trauma-informed care worsened across time. Sustained trauma-informed care was associated with implementation milestone completion and third-party ratings of quality improvement skills during the LC. Building capacity for organizational change through training and skill development during active phases of implementation is important for sustained trauma informed care in behavioral health service.