High-intensity Services Research Articles

Intensity of Social Needs Case Management Services and Changes in Hospital and Emergency Department Use Among Adult Medicaid Beneficiaries.

We identify the association between high- and low-intensity case management services on hospital and emergency department (ED) use among CommunityConnect patients. Social needs case management services vary in intensity, including the modality, workforce specialization, and maximum caseload. CommunityConnect is a social needs case management program implemented by Contra Costa Health, a county safety-net health system in California's San Francisco Bay Area. Due to the endogeneity of high-intensity services assigned to high-risk patients, we instrument for service intensity using the number of specialist case managers hired each month of enrollment. Zero-inflated negative binomial models with 2-stage residual inclusion estimated total and avoidable hospital admissions and ED visits 12 months post-enrollment for adult Medicaid beneficiaries enrolled between August 2017 and December 2018 (n = 19,782). Compared with low-intensity case management, high-intensity services were associated with a reduction in the incidence rates of inpatient admissions [incidence rate ratio (IRR) = 0.341, 95% CI: 0.106-1.102; P = 0.072], ED visits (IRR = 0.608, 95% CI: 0.188-1.965; P = 0.058), and avoidable ED visits (IRR = 0.579, 95% CI: 0.179-1.872; P = 0.091). No significant association was found between service intensity and the likelihood of an event being an excess zero. High-intensity social needs case management may be more effective than low-intensity service at reducing health care use for individuals with non-zero use, suggesting that intensive case management may be especially helpful in supporting discharge and transitions of care.

Targeting Community-Based Palliative and Serious Illness Care Resources: Challenges of More Stringent Diagnostic Criteria for Prospective Enrollment.

Background: For patients with serious illnesses, one aim of palliative care services is to reduce the frequency and severity of hospital-based episodes of care. Since hospital-alternative palliative care may consume costly resources, providers need to efficiently target high-intensity services toward those most at risk for such adverse episodes of care. Objective: Our objective was to investigate progressively more restrictive diagnosis-based indications of serious illness as used to prospectively identify patients with higher average rates of hospitalization. Design/Setting: We designed an observational cohort quality improvement study using historical Medicare claims records to evaluate diagnostic inclusion criteria for targeting palliative and serious illness care resources. We first isolated a Seriously Ill Population (SIP) and then defined More SIP and Most SIP subgroups. Measurements: Our primary outcome measure was the 2019 acute-care count of hospitalizations for patients in the SIP, More SIP, and Most SIP subgroups, respectively. Results: The More SIP and Most SIP subgroups exhibited higher hospitalization rates. However, they also excluded progressively more seriously ill patients who did experience hospitalizations. In addition, almost half of the Most SIP subgroup were not hospitalized at all, despite having an average hospitalization rate greater than one. Conclusion:Allocating resources (personnel and services) toward reducing hospitalizations when almost half of the targeted population never goes to the hospital could result in unnecessary expenditures and exclude patients that could potentially benefit. Engaging community-based services to detect changes in status could provide supplemental indications of when and for whom to target palliative care resources.

Slipping Through the Cracks: Clinicians' Perspectives on the Gaps in New York City's Public Mental Health System.

Most people who seek mental health treatment cannot access it. Certain groups (e.g., Medicaid enrollees and the uninsured) face particularly severe treatment access barriers along the care continuum. We interviewed 31 clinicians across two studies about their perspectives working in New York City's public mental health system. Because every clinician across both studies reported gaps in the system, we deployed an emergent, "serendipitous finding" approach and qualitatively analyzed the interviews together. Clinicians described three public mental health system gaps. First, many treatment-seekers must wait long periods of time to receive care and some never receive it at all. Second, patients with more serious challenges cannot access longer-term, higher-intensity, or specialized treatment. Third, some patients receiving high-intensity services may benefit from lower-intensity mental health support that is better integrated with medical and social service support. Coordinated and sustained financial investments at every step of the mental healthcare continuum are needed.

The longitudinal dispositions of people diagnosed with adjustment or severe stress disorders

BackgroundAdjustment and stress-related disorders are prevalent among psychiatric service users. Despite their prevalence, little is known about their prognosis. To reduce that gap, the present article documents the service use and diagnostic outcomes of people with adjustment or stress-related disorders presenting at Singapore’s largest psychiatric emergency department.MethodsAdministrative data from 2014 to 2021 was retrieved to follow a group of 683 service users whose first-ever psychiatric presentation in 2014 warranted a diagnosis of adjustment or stress-related disorder. People were grouped a priori depending on whether different diagnoses were recorded within 7 days, 9 months, after 9 months or not at all. Survival curves characterized conversion to other diagnoses and engagement with healthcare services. Service use outcomes include the number of hospitalizations, outpatient appointments, emergency department visits, and prescriptions.ResultsSixty-one percent (n = 417) never received another diagnosis over the 8-year period. This group used emergency services most and received the most pharmacotherapy shortly after their first visit. Of those who received another diagnosis, depression, personality disorders, and psychotic disorders were the most common. Those who received another diagnosis within 7 days (n = 70, 10%) received it on their first day of hospitalization (IQR 1–1), making the most use of inpatient services. The group who received another diagnosis within 9 months (n = 105, 15%) did so after 42 days (IQR 26–84) and had the highest relative number of deaths. Those who received another diagnosis after 9 months (n = 91, 13%) did so after 1,134 days (IQR 613–1,823) and had the longest period of engagement but made the least use of any psychiatric service, potentially suggesting a group whose early index diagnosis heralded vulnerability to future disorders.ConclusionsA large group of service users with acute stress or adjustment disorders will likely never be given another psychiatric diagnosis and appear to disengage following an initial period of high-intensity service use. The group that received a different diagnosis after the 9-month mark had prolonged contact with services but low intensity of service use and may represent a target for preventative intervention to help them improve their stress-managing skills and avoid developing other disorders.

Research on structural damage identification method of aircraft aluminium alloy skin based on power spectral entropy

Skin is an important structural component which covers the surface of aircraft widely, the structural health of skin has a great impact on the overall safety of aircraft. Due to the harsh operating environment, complex and changing working conditions, and high-intensity service process of aircraft, it is easy to cause damage to the skin. Thus, the in-situ health monitoring for aircraft skin is an effective approach to ensure its safety and reliability. Thanks to the ability of Lamb waves to propagate over long distances and recognize small-scale defects, they have shown great potential in the health monitoring of thin-walled structures and have received widespread attention. However, the traditional Lamb wave-based damage identification methods generally suffer from the problems of large number of sensors and low efficiency. Therefore, a skin damage identification method based on power spectral entropy is proposed in this paper, which can estimate the damage extent by extracting the nonlinear component increase caused by damage, and the experiments validate that the proposed method has higher sensitivity and computational efficiency than the existing other entropy-based methods.

Exploring the value of a structured trauma-pathway in improving traumainformed care within a Veterans’ High Intensity Service

IntroductionThe value of using trauma-informed approaches in the way services and systems deliver care is well recognised. This evaluation aimed to consider the value of using a structured ‘trauma pathway’ to improve trauma informed care within a veterans’ high intensity service.MethodA mixed-methods design was employed. Practitioners completed questionnaires via an online platform and also attended a focus group to share their views. Qualitative data were analysed using inductive thematic analysis.ResultsA total of 14 team members were eligible to take part. 14 submitted Pre data, and 8 submitted Post data. There were significant differences between pre and post data relating to consideration of trauma-informed care, and confidence in trauma assessment and intervention skills. However, levels of significance were not met for the differences in confidence around identifying pathways of care. From analysis of the qualitative data three main themes were identified 1) Quality of care and Trauma focus, 2) Practitioner experience and 3) Veteran Experience which are explored within the discussion.ConclusionsThe use of a structured pathway improved the delivery of a trauma-informed care approach within a high intensity service for veterans, with positive changes in both practitioner and veteran experiences

Evaluating the Effectiveness of Targeted Non-pharmaceutical Interventions to Reduce Accident and Emergency Attendance Among Adult High Intensity Service Users within the United Kingdom: A Systematic Review

Evaluating the Effectiveness of Targeted Non-pharmaceutical Interventions to Reduce Accident and Emergency Attendance Among Adult High Intensity Service Users within the United Kingdom: A Systematic Review

A multi resonant wave-absorbing honeycomb sandwich structure with excellent electrical performance damage tolerance

Wave-absorbing honeycomb sandwich structure (HSS) is widely used in aviation equipment, playing an important role in the integration of load-bearing and stealth shielding. The high-intensity service of aviation equipment beyond design condition accelerates damage and complicates failure triggers. In this work, a decentralized construction strategy with multiple resonant absorption peaks is proposed to enhance the electrical performance damage tolerance (EDT) of wave-absorbing HSS in 4–18 GHz frequency band. The designed multi resonant absorption peaks for 30 mm thick wave-absorbing honeycomb with 1 mm thick SiO2 fiber reinforced epoxy resin (SiO2f/ER) composites as top and bottom panels occur in the vicinity of 5 GHz, 9 GHz, 13 GHz, and 17 GHz, respectively. When the panel damage area accounts for 72 % or the penetrating damage area accounts for 18 %, the effective absorption bandwidth (EAB) of proposed HSS covers 4–18 GHz, indicating excellent EDT. By analyzing the normalized impedance, Smith chart, as well as power loss density, the excellent EDT is attributed to the pinning effect at each resonant frequency point, which benefits both impedance matching and electromagnetic wave (EMW) attenuation.

Integration of Antifouling and Anti-Cavitation Coatings on Propellers: A Review

The performance of an entire ship is increasingly impacted by propellers, which are the essential components of a ship’s propulsion system that have growing significance in a variety of aspects. Consequently, it has been a hot research topic and a challenge to develop high-performance antifouling and anti-cavitation coatings due to the issue of marine biofouling and cavitation faced by propellers in high-intensity service. While there is an overwhelming number of publications on antifouling and anti-cavitation coatings, a limited number of papers focus on integrated protective coatings on propellers. In this paper, we evaluated the development of antifouling and anti-cavitation coatings for ship propellers in the marine environment as well as their current status of research. These coatings include self-polishing antifouling coatings, fouling-releasing antifouling coatings, and biomimetic antifouling coatings for static seawater anti-biofouling, as well as anti-cavitation organic coatings and anti-cavitation inorganic coatings for dynamic seawater anti-cavitation. This review also focuses both on the domestic and international research progress status of integrated antifouling and anti-cavitation coatings for propellers. It also provides research directions for the future development of integrated antifouling and anti-cavitation coatings on propellers.

Evaluation of the NHS England ‘Op COURAGE’ High Intensity Service for military veterans with significant mental health problems

IntroductionIn November 2020, The NHS for England launched a pilot High Intensity Service (HIS) programme for treating military veterans complex mental health problems. Seven regional grants were awarded to manage...

Homelessness Prevention Interventions for Single Adults at Risk of or Experiencing MEH: A Systematic Review on their Effectiveness

Homelessness prevention for single adults at risk of or experiencing multiple exclusion homelessness (MEH) has received limited attention in research. This systematic review focused on the effectiveness of primary, secondary, and tertiary homelessness prevention interventions and strategies for this population. We searched four databases (Embasse, PsycInfo, Medline, and Allied Social Sciences Index and Abstracts [ASSIA]) for peer-reviewed empirically completed quantitative and qualitative studies and systematic reviews between 1992 and 2021. We identified ten categories of interventions based on the kind of support they provide: accommodation, financial assistance, case management, outreach, mental health care, joint mental health and substance use care, substance use care, other social support, policies and legal assistance. We found that research has principally focused on tertiary prevention, the prevention of chronic homelessness, and there is a lack of research on the effectiveness of upstream primary prevention strategies that would intervene before someone is at imminent risk of homelessness. However, within the secondary and tertiary prevention space, the best approach was a multifaceted cross-sector collaboration of different services. Many studies concluded that those at risk of or experiencing MEH require high intensity services combining a range of housing and support service options. Housing First, Assertive Community Treatment, Critical Time Intervention were high intensity services that were consistently found to be effective in preventing homelessness. Intensive case management had mixed evidence on effectiveness. Financial assistance was identified as important for preventing first-time, recurrent, and chronic homelessness in many studies and may be essential, but unlikely to be enough on its own. Finally, the prevention of homelessness after discharge from institutional care was found to be critical with several interventions showing to be effective here.

Discharge destinations for young people with a first episode of psychosis after attending an early intervention for psychosis service.

Early intervention for psychosis services result in superior outcomes in the domains of symptomatic and functional recovery, hospitalisation and employment compared to standard services; however, the optimal duration of care with these services is unknown. Knowledge on the discharge destinations, specifically the proportion discharged to high- and low-intensity services, could provide insights into the proportion of who may require a longer tenure of care. This study aimed to determine (1) the discharge destinations from early intervention for psychosis services and (2) baseline and intra-episode factors associated with discharge to the secondary care/adult mental health service. This study was conducted at the Early Psychosis Prevention and Intervention Centre in Melbourne and included all young people treated by the service with a first episode of psychosis over a 6-year period. Discharge destinations were categorised according to high-intensity services, namely, secondary mental health care, or lower intensity services, such as private practitioners or primary care. A total of 1101 young people with a first episode of psychosis were included in the study, of whom 58.8% were male and the median age was 20.0 years (interquartile range: 17-22). After a median of 95.4 weeks (interquartile range: 66.7-105.7), 36.6% were discharged to the adult mental health services, which was associated with being not in employment, education or training at presentation (odds ratio = 1.71, 95% confidence interval [1.23, 2.37]); experiencing a relapse (odds ratio = 1.76, 95% confidence interval [1.24, 2.49]); and being admitted to a mental health unit (odds ratio = 3.98, 95% confidence interval [2.61, 6.09]). Young people who lived with their parents were less likely to be discharged to secondary care services (odds ratio = 0.52, 95% confidence interval [0.37, 0.73]), as were those who were achieving symptomatic remission within 12 weeks (odds ratio = 0.60, 95% confidence interval [0.43, 0.83]). Migrant status and the duration of untreated psychosis were not associated with discharge destination. These findings indicate that there is a sizable, identifiable minority who may benefit from a longer episode of care with early intervention for psychosis services.

Relative Productivity of For-Profit Hospitals: A Big or a Little Deal?

This study asks: Does the empirical evidence support the conclusion that for-profit (FP) hospitals are more productive or efficient than private not-for-profit (NFP) hospitals or non-federal public (PUB) hospitals? Alternative theories of NFP behavior are described. Our review of individual empirical hospital studies of quality, service mix, community benefit, and cost/efficiency in the United States published since 2000 indicates that no systematic difference exists in cost/efficiency, provision of uncompensated care, and quality of care. But FPs are more likely to provide profitable services, higher service intensity, have lower shares of uninsured and Medicaid patients, and are more responsive to external financial incentives. That FP hospitals are not more efficient runs counter to property rights theory, but their relative responsiveness to financial incentives supports it. There is little evidence that FP market presence changes NFP behaviors. Observed differences between FP and NFP hospitals are mostly a "little deal."

Productivity determinants in the service industry: differences between high and low knowledge intensive sectors

PropósitoLa industria de servicios se ha convertido en un sector importante para el crecimiento económico, particularmente en los países en desarrollo. En este contexto, el objetivo de este artículo es comparar los determinantes de la productividad entre empresas que operan en sectores de servicios de baja y alta intensidad de conocimiento (LKIS y HKIS) en Ecuador.Diseño/metodología/enfoqueUtilizamos un método de estimación de dos pasos. En primer lugar, estimamos la productividad de las empresas y, en segundo lugar, los determinantes de la productividad. Para esto, utilizamos una base de datos de panel no balanceado sobre los estados financieros de las empresas formales ecuatorianas de los años 2007 a 2018.HallazgosNuestros resultados muestran que las empresas LKIS son ligeramente más intensivas en mano de obra en comparación con las empresas HKIS. Los determinantes de la productividad son similares entre las empresas HKIS y LKIS, excepto por las exportaciones y la concentración del mercado. Las empresas HKIS son más productivas cuando el nivel de competencia es bajo, lo que indica que un mayor poder de mercado está asociado con una mayor productividad. La influencia de los impuestos sobre la productividad depende del tamaño de la empresa. Las pequeñas y medianas empresas se ven más negativamente afectadas que las grandes empresas.Implicaciones prácticasLos impuestos deben diseñarse considerando el tamaño de las empresas, ya que podrían afectar su productividad. Por lo tanto, impuestos más bajos para las pequeñas y medianas empresas pueden reducir la desigualdad entre el tamaño de las empresas. Además, el conocimiento que tienen las HKIS debe extenderse a otras empresas convirtiéndose en una externalidad positiva en lugar de una barrera de entrada.Originalidad/valorA pesar de que los determinantes de la productividad del sector servicios se han explorado recientemente, en contraste con el sector manufacturero, los determinantes individuales y contextuales están menos identificados. En este artículo utilizamos un amplio conjunto de características de las empresas que podrían afectar la productividad en las empresas de servicios.

Veterans affairs serious mental illness patients: Differences in high-intensity service use by personality disorder status.

Individuals with serious mental illnesses (SMI) or personality disorders (PD) have complex treatment needs and are at risk of adverse outcomes. Yet, little is known about the impact of comorbid SMI and PD on risk factors. This study used the Veterans Health Administration (VHA)'s corporate data warehouse (CDW) to assess the differences between those with and without a comorbid PD, as well as the prevalence and impact of PD diagnoses on high-intensity/emergency service utilization in VHA patients with a SMI diagnosis (schizophrenia spectrum disorders and bipolar spectrum disorders). In fiscal year 2018, 163,904 VHA patients had encounters that listed SMI diagnoses, including 9,216 patients who had encounters that listed PD diagnoses. Bivariate analyses and logistic regression were used to compare group characteristics and determine whether a PD diagnosis was associated with utilization of high-intensity care services. The SMI with no PD and SMI with comorbid PD (SMI-PD) groups differed in terms of demographic, medication, clinical, and service utilization characteristics, including that the SMI-PD group was 5.25 times more likely to have documented suicide risk and 4.73 times more likely to have documented behavioral risk. After controlling for multiple patient characteristics, patients in the SMI-PD group were 1.35 times more likely to have some emergency department (ED) utilization and 1.94 times more likely to have some inpatient mental health use. Having a diagnosed comorbid PD was associated with increased prevalence of medical and psychiatric problems. Findings suggest that patients with comorbid PDs have particularly high-treatment needs and may benefit from assessment of, and adapted treatments for, PDs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The medium-high and high technological intensity sectors in Mexico and Brazil: a structural decomposition analysis between 2000-2014

We develop a structural decomposition analysis (SDA) to identify the importance of mid-high and high technological intensity (MH&HT) manufacturing and services to the changes in gross output for Brazil and Mexico between 2000 and 2014. We break down the output changes in the composition and level of final demand, the production technique (technical coefficients), and the trade pattern (share of imports in the total supply of inputs and final goods). The results show that the MH&HT importance tends to be pro-cyclical in the two economies, increasing during periods of more remarkable economic growth (2000-2008 for Brazil and 2010-2014 for Mexico). This relation tends to be perceived for manufacturing and less so for services.

Comparing Service Use and Costs of Individual Placement and Support With Usual Vocational Services for Veterans With PTSD

Among veterans with posttraumatic stress disorder (PTSD), supported employment that utilizes the individual placement and support (IPS) model has resulted in consistently better employment and functional outcomes than usual vocational rehabilitation services. This study aimed to compare these two approaches in terms of health services use and associated costs. A secondary analysis of a multisite randomized controlled trial of 541 unemployed veterans with PTSD used archival data from electronic medical records to assess the use and costs of health services of IPS and usual care (i.e., a transitional work [TW] program) over 18 months. Comparisons were also made to an 18-month postintervention period. The two study groups did not differ in number of inpatient days or in utilization or cost of high-intensity services. Annual per-person costs of health services were approximately 20% higher for IPS than for TW participants (mean difference=$4,910 per person per year, p<0.05) during the intervention period, largely driven by higher utilization and costs for vocational services in the IPS group (p<0.001). These costs declined postintervention to nonsignificant differences. The mean annual per-person vocational service cost was $6,388 for IPS and $2,549 for TW (mean difference=$3,839, p<0.001) during the intervention period. In keeping with IPS’s intensive case management approach, veterans receiving IPS used more vocational services and had correspondingly higher costs than veterans receiving TW. The two groups did not differ in use or cost of other types of health services. Future research should examine whether higher short-term costs associated with IPS relative to usual care result in long-term cost savings or higher quality of life for persons with PTSD.

The Export of High Knowledge Intensity Services of European Countries

The Export of High Knowledge Intensity Services of European Countries

Psychosocial and behavioral therapy in conjunction with medication for opioid use disorder: Patterns, predictors, and association with buprenorphine treatment outcomes

IntroductionCurrent evidence indicates that buprenorphine is a highly effective treatment for opioid use disorder (OUD), though premature medication discontinuation is common. Research on concurrent psychosocial and behavioral therapy services and related outcomes is limited.The goal of this study was to define patterns of OUD-related psychosocial and behavioral therapy services received in the first 6 months after buprenorphine initiation, identify patients' characteristics associated with service patterns, and examine the course of buprenorphine treatment, including the association of therapy with medication treatment duration. MethodsWe analyzed 2013–2018 MarketScan Multi-State Medicaid claims data. The sample included adults aged 18–64 years at buprenorphine initiation with treatment episodes of at least 7 days (n = 61,976). We used group-based trajectory models to define therapy service patterns and multinomial logistic regression to identify pre-treatment patient characteristics associated with therapy trajectories. Multinomial propensity-score weighted Cox proportional hazards regression estimated time to buprenorphine discontinuation and unweighted Cox proportional hazards models estimated risk of adverse health care events during buprenorphine treatment (all-cause and opioid-related inpatient and emergency department services, overdose treatment). ResultsWe identified three trajectories of psychosocial and behavioral therapy services: none (73.8%), low-intensity (17.2%), and high-intensity (9.0%). Compared to those without therapy, low-intensity and high-intensity service patterns were associated with behavioral health diagnoses and medical treatment for opioid overdose in the baseline period prior to buprenorphine initiation. The hazard of buprenorphine discontinuation was significantly lower for low-intensity (HR = 0.55; 95% CI, 0.54–0.57) and high-intensity (HR = 0.71; 95% CI, 0.67–0.74) therapy groups compared to those without therapy services. Yet patients in the high-intensity therapy group had increased risk of opioid-related health care events during buprenorphine treatment, including medical treatment for opioid overdose (HR = 1.29; 95% CI, 1.01–1.64). ConclusionMost patients received little or no OUD-related psychosocial and behavioral therapy after initiating buprenorphine treatment. Patients who received therapy had characteristics indicating greater treatment needs as well as more complex treatment courses. Concurrent therapy services may help to address premature buprenorphine discontinuation, particularly for patients with high-risk clinical profiles; however, future prospective research should determine whether therapy is effective for extending buprenorphine retention.

The Impact of Mental Health Intensive Case Management on Functioning and Clinical Outcomes of Older Black and White Veterans With Serious Mental Illness

ObjectivesTo examine differences in service delivery, functioning, and clinical outcomes between older Black and White veterans participating in a national Veterans Health Administration (VHA) program of intensive case management. DesignSecondary analysis of national program evaluation data. SettingVHA Intensive Community Mental Health Recovery (ICMHR) program. ParticipantsBlack (n = 1327) and White (n = 4402) veterans age 55 and older who enrolled in ICMHR between 2000-2013. MeasurementsMeasures evaluated sociodemographic factors, service delivery, functioning, and clinical outcomes. ANOVA and chi-squares were used to evaluate differences in enrollment characteristics and service delivery between Black and White veterans. Regression analyses were used to examine changes in outcomes over 6 months controlling for confounding baseline differences and service delivery. Cohen's d of .20 was used as a threshold for a clinically meaningful effect. ResultsBlack veterans were more likely to be diagnosed with schizophrenia, alcohol use disorder, and drug use disorder. Although case managers spent significantly less time with Black veterans, there was no difference in the frequency of contacts. Medication management and substance use treatment were more often provided to Black veterans. Black veterans experienced substantially greater improvement in anxiety/depression than White veterans with a small effect size (Cohen's d =-0.25). Changes in all other outcome measures did not meet criteria for clinically meaningful differences. ConclusionsBlack veterans experienced meaningfully greater improvements than White veterans on anxiety/depression but not on other measures. Provision of high-intensity services in an equal-access setting may reduce health disparities between Black and White older adults with serious mental illness.