Complex Behavioral Health Research Articles

A (Dis)orderly Progression: The Lasting Impact of Pandemic on Community-Based Organizations

ABSTRACT Community-based organizations (CBOs) serving older ethnic minority adults, especially older immigrants, are vital to satisfy their complex social, health, and behavioral health needs. This study uses organizational theories and a case study approach to examine how the organizational responses to the multifaceted impact of the COVID-19 pandemic and progress beyond the pandemic-related responses. Four CBOs serving older Chinese immigrants in New York City were examined. Results indicate that driven by unmet psychosocial needs of older Chinese immigrants and public health measures, CBOs modified practice protocols and established (or strengthened) collaborative relationships with medical providers and other CBOs. COVID-19 responses include CBOs’ transformations in organizational structures (e.g. collaboration) and operational activities (e.g. telehealth). Successful transformations of CBOs were primarily due to prior adaptiveness to integrated care reform and assured needed resources before the pandemic; the transformation reflected orderly organizational progress rather than a temporary management strategy.

Advancing Behavioral Health Equity Through Telehealth and Remote Training of Newly Certified Psychiatric-Mental Health Nurse Practitioners.

Rural communities are disproportionately impacted by acute shortages of mental health providers. This problem, combined with complex behavioral health conditions, elicited the need for a university-based, remote telepsychiatric traineeship for newly board certified psychiatric-mental health nurse practitioners (PMHNPs). The Psychiatric Advanced Practice Registered Nurse TechNology Enhanced Residency (PARTNER) Program was developed to advance behavioral health equity by increasing state-wide access to care, removing geographical barriers, and enhancing PMHNP workforce readiness by strengthening trainees' ability to manage complex behavioral health conditions. In a southeastern state over a period of 3 years, six PMHNPs cumulatively provided behavioral health services to 1,195 patients, managed >118 diagnoses, and completed 3,535 visits, with 95.6% of visits comprising provision of care to patients residing in rural areas. Care was provided through the implementation of a collaborative-interdisciplinary-care model provided by route of telehealth and comprising a partnership between PMHNPs and patients' primary care providers. The training program enhanced providers' clinical proficiency, improved patient outcomes, and increased the number of skilled providers trained to manage patients with complex behavioral health conditions. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 19-24.].

Police-mental health co-response versus police-as-usual response to behavioral health emergencies: A pragmatic randomized effectiveness trial

BackgroundPeople with mental illness are overrepresented in United States (US) criminal legal systems. In response, alternatives to traditional police response to behavioral health emergencies have become more common, despite limited evidence for their effectiveness. We conducted the first randomized controlled trial of a police-mental health co-response team to determine program effectiveness relative to a police-as-usual response on key outcomes identified by community stakeholders. MethodsBetween January 2020 and March 2021, we randomized behavioral health emergency calls for service in one of six police districts in Indianapolis, Indiana to receive a co-response or police-as-usual response during operational hours between 10 a.m. and 5 p.m. Mondays – Fridays. Eligible calls for service were determined via pre-specified phrases indicating a behavioral health incident over the police dispatch radio. Researchers then communicated random assignment with the co-response team to indicate whether they should respond or withhold. Logistic and negative binomial regression were used to assess group differences in emergency medical services (EMS) events within 12 months of the randomized incident along with jail booking, outpatient encounters, and emergency department visits. FindingsWe randomized 686 calls for service with co-response completed in 264 cases and police-as-usual response in 267 cases. The overall rate of attrition was similar across conditions and the final sample included 211 co-responses and 224 police-as-usual responses. We found no significant differences in any EMS event (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 0.85–1.88, p = .246) or event counts (incidence rate ratio [IRR]: 0.85; 95% CI: 0.52–1.37, p = .504). We also found no differences in secondary outcomes (jail booking, outpatient encounters, and emergency department visits). DiscussionA police-mental health co-response team model was not more effective than traditional police response on key outcomes. Co-response team models, such as the one reported here, may unintentionally foster emergency services utilization among persons with behavioral health needs. Without a functioning national mental health system, communities in the US will continue to struggle to identify solutions to meet the needs of community members with complex behavioral health issues.

Implementing a tobacco-free workplace program at a substance use treatment center: a case study

BackgroundPeople with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center.MethodsThis study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff (n = 6) and clients (n = 16) at the substance use treatment center and site visits (n = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice.ResultsStaff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center.ConclusionsSubstance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Child Health Needs and the Developmental-Behavioral Pediatrics Workforce Supply: 2020-2040.

Developmental-behavioral pediatrics (DBP) subspecialists care for children with complex neurodevelopmental and behavioral health conditions; additional roles include education and training, advocacy, and research. In 2023, there were 1.0 DBP subspecialists per 100 000 US children aged 0 to 17 years (range 0.0-3.8), with wide variability in DBP subspecialist distribution. Given the prevalence of DB conditions, the current workforce is markedly inadequate to meet the needs of patients and families. The American Board of Pediatrics Foundation led a modeling project to forecast the US pediatric subspecialty workforce from 2020 to 2040 using current trends in each subspecialty. The model predicts workforce supply at baseline and across alternative scenarios and reports results in headcount (HC) and HC adjusted for percent time spent in clinical care, termed "clinical workforce equivalent." For DBP, the baseline model predicts HC growth nationally (+45%, from 669 to 958), but these extremely low numbers translate to minimal patient care impact. Adjusting for population growth over time, projected HC increases from 0.8 to 1.0 and clinical workforce equivalent from 0.5 to 0.6 DBP subspecialists per 100 000 children aged 0 to 18 years by 2040. Even in the best-case scenario (+12.5% in fellows by 2030 and +7% in time in clinical care), the overall numbers would be minimally affected. These current and forecasted trends should be used to shape much-needed solutions in education, training, practice, policy, and workforce research to increase the DBP workforce and improve overall child health.

Mis-implementation of evidence-based behavioural health practices in primary care: lessons from randomised trials in Federally Qualified Health Centers.

Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. "Mis-implementation" refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange. We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs). We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors. Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic. Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.

Predicting the Behavioral Health Needs of Asian Americans in Public Mental Health Treatment: A Classification Tree Approach.

Given the fact that experiencing pandemic-related hardship and racial discrimination worsen Asian Americans' mental health, this study aimed to identify unique characteristics of behavioral health needs among Asian Americans (N = 544) compared to White Americans (N = 78,704) and Black Americans (N = 11,252) who received publicly funded behavioral health services in Indiana before and during the COVID-19 pandemic. We used 2019-2020 Adults Needs and Strengths Assessment (ANSA) data for adults eligible for Medicaid or funding from the state behavioral health agency. Chi-squared automatic interaction detection (CHAID) was used to detect race-specific differences among demographic variables, the pandemic status, and ANSA items. Results indicated that, regardless of age, gender, or pandemic status, Asian Americans who received behavioral health services, struggled more with cultural-related factors compared to White and Black individuals. Within this context, intersections among behavioral/emotional needs (psychosis), life functioning needs (involvement in recovery, residential stability, decision making, medical/physical health), and strengths (job history, interpersonal, and spiritual) further differentiated the mental health functioning of Asian from White and Black Americans. Classification tree algorithms offer a promising approach to detecting complex behavioral health challenges and strengths of populations based on race, ethnicity, or other characteristics.

Information sharing to support care transitions for patients with complex mental health and social needs.

Patients with complex behavioral and mental health conditions require significant transitional care coordination. It is unclear how skilled nursing facilities (SNFs) that serve these patients engage in care transfer with hospitals, specifically whether they experience discrepancies in the type of information shared by hospital partners and/or use different approaches to secure needed information. Cross-sectional analysis of a national 2019-2020 SNF survey that collected information on transitional care practices with referring hospitals; respondents were directors of nursing services. We used chi-squared tests and descriptive statistics to characterize hospital information sharing practices experienced by facilities that accept complex patients (e.g., serious mental illness, substance use disorder, and/or medication assisted treatment), and to compare them to facilities that treat a less complex population. A total of 215 SNFs had sufficiently complete responses for inclusion in the analysis. Of these respondents, 57% accepted two or more types of patients with complex conditions of interest; these SNFs were more likely to be urban, for-profit, and serve more dual-eligible patients. SNFs accepting complex patients experience information sharing on par with other facilities, and are more likely to receive information on behavioral, social, mental, and functional status (25.41% vs. 12.90%; p=0.023). These facilities are also more likely to consistently use electronic methods (e.g., an online portal, shared electronic health record [EHR] access) to retrieve information from partner hospitals. SNFs accepting complex patients demonstrate some evidence of enhanced information retrieval via electronically mediated pathways. Overall, information sharing remains underdeveloped in this care context. Policymakers should continue to prioritize widespread digital infrastructure that supports post-acute care delivery.

The Integrated Care for Kids Model: Addressing Fragmented Care for Pediatric Medicaid Enrollees in Seven Communities.

Children with complex health and behavioral health conditions face challenges accessing coordinated health and community-based services. Adverse childhood experiences (ACEs), social determinants of health, and care delivery silos can lead to negative long-term outcomes. This paper provides an update on the Integrated Care for Kids (InCK) model from the Centers for Medicare & Medicaid Services' Innovation Center and discusses barriers and facilitators to program implementation in the seven communities. The three core InCK activities-supported by flexible alternative payment models-are early identification, risk stratification, and service integration. Challenges include obtaining the appropriate Medicaid and Children's Health Insurance Program (CHIP) authorities, sharing data across non-traditional partners, assessing impact in non-clinical domains, and evaluating the program's impact on child health. InCK enables innovation in value-based purchasing by creating a guiding framework that allows states to design and implement a service delivery and payment model that accounts for the heterogeneity of Medicaid programs.

Evaluation of New York/New York III permanent supportive housing program

In 2005, the city and state of New York launched New York/New York III (NY/NY III), a permanent supportive housing program for individuals experiencing homelessness or at risk of homelessness with complex medical and behavioral health issues. This review paper summarizes a decade of findings (2007–2017) from the NY/NY III evaluation team, to analyze this program’s impact on various housing and health outcomes. The evaluation team linked NY/NY III eligible persons with administrative data from two years pre- and two years post-eligibility and compared housing and health outcomes between placed and unplaced groups using propensity score analysis. Placement into NY/NY III housing was associated with improved physical and mental health outcomes, increased housing stability, and statistically significant cost savings per person after one year of placement. The evaluation team recommends that municipalities invest in supportive housing as a means for mitigating homelessness and improving health outcomes in this vulnerable population.

Partnering to prepare: An academic/workforce collaboration to develop disaster shelter training for nurses.

In California, more frequent, intense, and destructive wildfires have prompted public health departments to enhance disaster response plans as evacuations and shelter needs increase. In addition, individuals utilizing shelters have increasingly complex medical and behavioral health needs and are accessing shelters for longer periods of time. Public health nurses (PHNs) are often called to staff disaster shelters but may have less recent experience in, or comfort with, direct patient care. Many health departments are experiencing challenges developing sustainable training infrastructure that prepares PHNs to deliver direct patient care in disaster shelters. Partnering with academic institutions can address this challenge. This article describes a partnership between a regional collaborative of health jurisdictions and a public university to train public health nurses to work in disaster shelters. The training demonstrates a sustainable way to instruct public health nurses while also highlighting the potential of partnerships between academic institutions and local health departments to address disaster preparedness and response needs in a community. Public health nurses are essential to public health preparedness and providing additional training can augment their ability to respond to disasters.

Advancing the behavioral health workforce: An innovative integrated care and substance use disorder training model to improve outcomes for people in medically underserved communities.

It is critical that we strengthen the ability of the behavioral health workforce to better manage the complex behavioral and physical health needs of people in medically underserved areas. Despite the knowledge that integrated care (IC) models improve patient outcomes and experience, provider satisfaction, and health care costs, educational and experiential training in IC is limited, limiting workforce capacity to deliver this care. Through the Health Resources and Services Administration-funded Rutgers University Integrated Substance Use Disorder Training Program (RUISTP), we partner with community-based primary care clinics to implement an interprofessional fellowship program for psychologists, social workers, physician assistants, and advanced practice nurses. The RUISTP simultaneously provides training and implements IC within these community-based systems. Our multiple-methods evaluation design examines data-driven indicators of feasibility, uptake, and program success during implementation and sustainability phases and assesses changes in organizational beliefs and practices, provider competencies, and service utilization throughout the project period. This article describes the significance and innovation of (a) an IC training program, (b) an implementation plan for sustained change within systems of care, and (c) evaluative methodology to assess and improve IC and SUD service delivery and training. These data will be used to create a template for other academic and health care systems nationally. It is the mission of this program to use an innovative training, implementation, and evaluation design to enhance IC and SUD services, bolster the behavioral health workforce trained to provide high-quality IC, and inform replications of this model in other geographic and clinical settings, particularly those in medically underserved communities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Broad and Adaptive Integrated Health Psychology Services: Engaging BIPOC Veterans in VA Healthcare.

Clinical health psychologists provide adaptive, evidenced-based interventions that incorporate behavioral medicine and behavioral health strategies, with the potential to integrate broadly across the medical system. Veterans Affairs (VA) healthcare strives to meet the needs of an increasingly diverse patient population with complex behavioral health needs. This conceptual paper describes an example of health psychology at one VA healthcare system, with a focus on adaptive and culturally responsive services reaching Black, Indigenous and People of Color/Veterans of Color (BIPOC). The clinical health psychology services and cases described aim to reach Veterans who may not participate in, or benefit as fully from, traditional disease self-management or mental health services. The authors offer recommendations, to secure the value and sustainability of these integrated health psychology services, and hopefully contribute to addressing healthcare inequities.

North Carolina's six BH MCOs unite on foster care services plan

North Carolina's six behavioral health managed care organizations (MCOs) have launched the N.C. Child and Family Improvement Initiative as a collective first move to providing an alternative to a proposed statewide foster‐care services plan, the Winston‐Salem Journal reported on June 4. Although spokespersons for the MCOs provided few details last week about the initiative, they expect “the immediate improvements resulting from this partnership will be fully functional before the planned Dec. 1, 2022 launch of the North Carolina Department of Health's Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans, an integrated care plan for people with serious behavioral health care needs, substance use disorder and/or disabilities. The MCOs said a primary goal of the initiative is to demonstrate their ability “to implement a statewide model to ensure seamless access to quality care for these children and families regardless of where they live in North Carolina. For those children with very complex behavioral health needs, often inclusive of intellectual/developmental disabilities needs, there are regularly challenges in securing needed treatment. Severe provider capacity issues and workforce shortages across the state have exacerbated these challenges.” The MCOs said their plan will address concern expressed by state legislators, county departments of social services, providers and families of service recipients.

An Ecodevelopmental Framework for Engaging Diverse Youth in Foster Care and Their Families Into Technology-Based Family Intervention Research Trials.

Family-based interventions delivered via telehealth are a promising mode for overcoming barriers to behavioral health treatment among youth in foster care and their families. There is a dearth of research, however, regarding effectiveness of these interventions for youth in foster care, who commonly exhibit complex behavioral health treatment needs. Clinical research in this area directly relates to equity in service access and quality for these youth and families, with numerous barriers and enabling factors to consider in order to improve engagement in clinical trials and bolster the evidence base. We present a framework to better understand the multi-systemic factors impacting youth and family engagement in clinical research on family-based telehealth interventions, drawing on relevant theory, including the bioecological model and ecodevelopmental theory. We also draw on our experiences conducting technology-based clinical research through the Family Telehealth Project, an evaluation of a brief family-based affect management intervention designed specifically for youth in foster care and their families, as a case example. Recommendations for promoting engagement in clinical research on family-based telehealth interventions with diverse youth in foster care and their families are provided.

Evaluation of a systems-level technical assistance program to support youth with complex behavioral health needs

The National Technical Assistance Network for Children’s Behavioral Health (TA Network) supports the development and implementation of Systems of Care (SOC) for youth with serious emotional disorders and their families in states, tribes, territories, and communities throughout the United States. The purpose of the current research was to conduct an evaluation of the TA Network to assess: The degree to which it has deployed research-based elements of TA; levels of participant satisfaction; types and scope of TA services provided; and systems-level outcomes. Study participants were drawn from a stratified random sample of SOC grant recipients who received technical support from the TA Network between 2013 and 2017. Results suggest that the TA Network has encompassed research-based elements of effective TA. Participants rated their interactions with the network very highly, and they accessed a wide variety of resources from the network. Finally, participants reported a variety of systems-level outcomes associated with TA Network support. Together, these findings underscore the importance of structuring TA systems to tailor support to fit with recipients’ needs, build positive, proactive relationships, and offer services of sufficient dosage. Given the lack of rigorous evaluations on provision of TA, future studies can confirm the degree to which such tailored approaches to TA result in increased satisfaction, more effective implementation of SOC principles, and ultimately improved outcomes for youth and families.

Programs to address substance use in U.S. children’s hospitals: Untapped potential for expanding community prevention and treatment resources

ObjectiveSubstance use affects Americans across the life course and there is need to understand how pediatric health care organizations implement new programs to address this need. The aim of this study was to understand what programs are currently offered and the institutional and community factors that predict hospitals undertaking this work. MethodsWe analyzed children’s hospitals’ community health needs assessments (CHNAs) and implementation strategies (2015–2019) to identify which hospitals were addressing substance use and categorized the programs they implemented. We conducted bivariate descriptive comparisons of hospitals that did or did not address substance use based on institutional, county-level, and community-benefit spending characteristics and calculated a logistic regression model to assess whether the extent of local need was associated with hospital service provision, independent of covariates. ResultsOnly 13% of children’s hospitals addressed substance use in their CHNA implementation strategies and of the 151 programs adopted, only 11 were pediatric-specific. The most common strategies hospitals outlined to address substance use included access to formal treatment and community outreach and education efforts. Children’s hospitals who did not address substance use in their communities were more likely to have worked independently on their community benefit plan and to work in counties with greater economic needs. The level of substance use needs in the community was not associated with hospital programs. Analysis of community benefit filings to the IRS confirmed that children’s hospitals not addressing substance use also spent fewer community benefit dollars on population health-related activities suggesting that overall spending may overlap with willingness to invest in complex behavioral health needs. ConclusionsFew children’s hospitals address substance use as a community health need, suggesting that these organizations are an underutilized resource for preventing and addressing the profound impact of substance use across the life course.

Mental health and substance use patterns associated with lifetime suicide attempt, incarceration, and homelessness: A latent class analysis of a nationally representative sample of U.S. veterans.

A substantial proportion of U.S. military veterans experience mental health and/or substance use disorders. As public awareness of these difficulties rises, so too does interest in the relation between veteran behavioral health and high-risk events, namely suicide attempts, incarceration, and homelessness. Using latent class analysis and a large, nationally representative sample of community veterans, the current study examined common patterns of veteran behavioral health disorders and the associations between these patterns and high-risk events. Results suggest four classes of veterans, including a "healthy" class (comprising 69% of the total sample), a "substance use disorder" class (16%), a "personality disorder-substance use disorder" class (8%), and a "depressive disorder" class (7%). Veterans in the healthy class had the lowest rates of suicide attempt (2%), incarceration (14%), and homelessness (3%), whereas veterans in the personality disorder-substance use disorder class had the highest rates of these events (27%, 45%, and 22%, respectively). Results attest to the importance of investing clinical resources into addressing the needs of veterans experiencing complex behavioral health patterns, particularly personality and substance use disorders. Implications for the health care of veterans are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Investigating the impact of caregiver transportation needs on Children's response to behavioral and mental health treatment: A longitudinal analysis

IntroductionDespite a rich and developing research literature on the relationships between transportation and healthcare outcomes, the impact of unmet transportation needs on children, particularly on their general psychosocial functioning, is less well understood. We hypothesized that caregiver's transportation needs may be a key point of intervention for child-level health outcomes, such that the resolution of caregiver transportation needs may have an important, downstream impact on other areas of the child's functioning. MethodsWe tested this hypothesis in a sample of children (n=4341) served in a large, statewide public behavioral healthcare system. We conducted a retrospective longitudinal analysis of children served in the system between March 2019 and March 2020, using a specialized assessment tool that captures a comprehensive range of psychosocial functioning: the Child and Adolescent Needs and Strengths (CANS; Lyons, 2009) assessment. ResultsLinear mixed-effects analyses demonstrated that, if caregivers’ transportation needs were resolved during the episode of care, those children demonstrated greater improvements on both need reduction and strength building across multiple domains than did their peers whose caregivers had unresolved transportation needs. By the end of the episode of care, children whose caregivers had resolved transportation needs were not significantly different than those children whose caregivers never had transportation needs. ConclusionsThe resolution of transportation needs may be an important focus for providers working with children with a complex behavioral health, such that the resolution of these transportation needs seems to have a large, positive downstream impact on their overall functioning.

Identifying Patterns of Pediatric Mental and Behavioral Health at End of Life: A National Study.

Children, who enroll in hospice, have complex mental and behavioral health (MHBH) problems. There is limited literature on patterns of these problems among children at their end of life. Using the national database of 6195 children enrolled in hospice between January 1, 2011, and December 31, 2013, and latent class analysis, this study identified 4 distinctive classes of children. Neurodevelopment and anxiety class (26.5% of the sample) had 41.3% of children of 15 years or older, who had an average of 1.4 MHBH comorbidities and took 17 medications; 29.1% had physical health comorbidities, and 23% were dependent on technology. In the Behavior and Neurodevelopment class (20%), 53.1% of the children were between ages 6 and 14 years, who had an average of 2 MHBH comorbidities and took 17 medications. In the Physiology class (43.4%), 65.5% of children were younger than 5 years, had 1 MHBH comorbidity, and took 19 medications. In the Mood, Behaviors, and Anxiety class (10.2%), more than 90% of children were older than 6 years, had 4 MHBH comorbidities, and took 30 medications. In the latter 3 classes, approximately half of the children either had physical health comorbidities or were technology dependent. These findings highlight the importance of end-of-life care that accounts for the likely presence of complicated patterns of MHBH conditions.