Large Care System Research Articles

Implementation of Cognitive Health Services in Large Systems of Care: Highlights From Coordinated Specialty Care for First Episode Psychosis.

With increasing recognition of the importance of cognitive health for recovery in people with psychosis, questions arise as to how to implement cognitive health services in large systems of care. This paper describes the implementation of cognitive health services in OnTrackNY (OTNY), a network of clinics delivering a Coordinated Specialty Care treatment model for early psychosis, with the goal of documenting the processes, challenges, and useful adaptations. In 2018, OTNY piloted a Cognitive Health Toolkit for implementation across 18 affiliated clinics. The toolkit intended to identify the cognitive health needs of individuals early in the course of psychosis and to integrate cognitive health into the vocabulary of wellness and recovery. Implementation involved creating mechanisms for staff training and support to, in turn, help participants improve how they use cognitive skills in daily life. The toolkit was disseminated to all 28 OTNY programs throughout New York state by 2023. When simple assessment and decision-making tools were embedded in routine care practices, the majority of participants identified that improving memory, attention, and critical thinking skills would be helpful. Consistently, about 70% of those asked wanted to learn more about how to better their cognitive health. Cognitive health services can be implemented in large systems of care that provide a multi-level system of implementation supports. Organizational facilitators of implementation include a training program to educate about cognitive health and the delivery of cognitive health interventions, and embedded quality assurance monitoring and improvement activities.

A randomized trial of brief couple therapy for PTSD and relationship satisfaction.

This three-arm randomized trial tested a brief version of cognitive-behavioral conjoint therapy (bCBCT) delivered in two modalities compared to couples' psychoeducation in a sample of U.S. veterans with posttraumatic stress disorder (PTSD) and their intimate partners. Couples were randomized to receive (a) in-person, office-based bCBCT (OB-bCBCT), (b) bCBCT delivered via home-based telehealth (HB-bCBCT), or (c) an in-person psychoeducation comparison condition (PTSD family education [OB-PFE]). Primary outcomes were clinician-assessed PTSD severity (Clinician Administered PTSD Scale), self-reported psychosocial functioning (Brief Inventory of Psychosocial Functioning), and relationship satisfaction (Couples Satisfaction Index) at posttreatment and through 6-month follow-up. PTSD symptoms significantly decreased by posttreatment with all three treatments, but compared to PFE, PTSD symptoms declined significantly more for veterans in OB-bCBCT (between-group d = 0.59 [0.17, 1.01]) and HB-bCBCT (between-group d = 0.76 [0.33, 1.19]) treatments. There were no significant differences between OB-bCBCT and HB-bCBCT. Psychosocial functioning and relationship satisfaction showed significant small to moderate improvements, with no differences between treatments. All changes were maintained through 6-month follow-up. A briefer, more scalable version of CBCT showed sustained effectiveness relative to an active control for improving PTSD symptoms when delivered in-person or via telehealth. Both bCBCT and couples' psychoeducation improved psychosocial and relational outcomes. These results could have a major impact on PTSD treatment delivery within large systems of care where access to brief, evidence-based PTSD treatments incorporating family members are needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Outcomes, evidence-based treatments, and disparities in a statewide outpatient children’s behavioral health system

Abstract Purpose Many questions remain about the effectiveness of behavioral health treatments for children in large systems of care, including the use of evidence-based treatments (EBTs). The goals of this study were to 1) describe outcomes of children receiving treatment in a statewide system, overall and separately for demographic groups; 2) describe penetration rates of EBTs and examine outcomes by treatment type and 3) examine moderation of treatment type by demographic group. Methods Participants were 46,399 children receiving behavioral health services at one of 25 outpatient clinics in a state system between 2013 and 2017. Administrative data included child demographic characteristics, treatment type, and problem severity based on the Ohio Scales. Propensity score methods were used to analyze EBT effects compared to no EBT conditions, and interactions with demographic groups. Results The overall pre- to post-treatment effect size across all treatment types was medium (Cohen’s d = 0.49 to 0.51) and similar to prior research. White children showed greater improvements than Black or Hispanic children, 7 to 12-year olds improved more than younger and older children, and females improved more than males. Almost half (47%) of children received cognitive behavioral therapy, and an additional 12.4% received another EBT. Children receiving EBTs showed greater improvement than those not receiving an EBT. The relative benefits of EBTs were mostly consistent across sex, age, and race/ethnicity, but EBTs were associated with some reductions in disparities by race/ethnicity (particularly for Hispanic youth and more modestly for Black youth) and age. Conclusions Outcomes for children receiving behavioral health treatment in a statewide system were modest. EBTs can be disseminated within large systems and have potential for improving overall outcomes for children from diverse backgrounds.

COVD-14. TELEMEDICINE REVIEW IN NEURO-ONCOLOGY: COMPARATIVE EXPERIENTIAL ANALYSIS FOR BARROW NEUROLOGICAL INSTITUTE AND GEISINGER HEALTH DURING THE 2020 COVID-19 PANDEMIC

Coronavirus disease 2019 (COVID-19) has grossly impacted how we deliver healthcare and how healthcare institutions derive value from the care provided. at increased infectious risk on immunosuppressive therapies and often have mobility limitations. Adapting to new technologies and reimbursement patterns were challenges that had to be met by the institutions while patients struggled with decisions to prioritize concerns and to identify new pathways to care. With the implementation of social distancing practices, telemedicine plays an increasing role in patient care delivery, particularly in the field of Neurology. This is of particular concern in our cancer patient population given that these patients are often at increased infectious risk on immunosuppressive therapies and often have mobility limitations. We reviewed telemedicine practices in neurology pre-/post-COVID-19 and evaluated the neuro-oncology clinical practice approaches of two large care systems, Barrow Neurological Institute and Geisinger Health. Practice metrics were collected for impact on clinic volumes, institutional recovery techniques, and task force development to address COVID-19 specific issues. Neuro-Oncology divisions reached >67% of pre-pandemic capacity (patient visits and slot utilization) within 3-weeks and returned to >90% capacity within 6-weeks of initial closures due to COVID-19. The two health systems rapidly and effectively implemented telehealth practices to recover patient volumes. While telemedicine will not replace the in-person clinical visit, telemedicine will likely continue to be an integral part of neuro-oncologic care. Telemedicine has potential for expanding access in remote areas and provides a convenient alternative to patients with limited mobility, transportation, or other socioeconomic complexities that otherwise challenge patient visit adherence.

Telemedicine review in neuro-oncology: comparative experiential analysis for Barrow Neurological Institute and Geisinger Health during the 2020 COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) has grossly affected how we deliver health care and how health care institutions derive value from the care provided. Adapting to new technologies and reimbursement patterns were challenges that had to be met by the institutions while patients struggled with decisions to prioritize concerns and to identify new pathways to care. With the implementation of social distancing practices, telemedicine plays an increasing role in patient care delivery, particularly in the field of neurology. This is of particular concern in our cancer patient population given that these patients are often at increased infectious risk on immunosuppressive therapies and often have mobility limitations. We reviewed telemedicine practices in neurology pre– and post–COVID-19 and evaluated the neuro-oncology clinical practice approaches of 2 large care systems, Barrow Neurological Institute and Geisinger Health. Practice metrics were collected for impact on clinic volumes, institutional recovery techniques, and task force development to address COVID-19 specific issues. Neuro-Oncology divisions reached 67% or more of prepandemic capacity (patient visits and slot utilization) within 3 weeks and returned to 90% or greater capacity within 6 weeks of initial closures due to COVID-19. The 2 health systems rapidly and effectively implemented telehealth practices to recover patient volumes. Although telemedicine will not replace the in-person clinical visit, telemedicine will likely continue to be an integral part of neuro-oncologic care. Telemedicine has potential for expanding access in remote areas and provides a convenient alternative to patients with limited mobility, transportation, or other socioeconomic complexities that otherwise challenge patient visit adherence.

The Role of State Context in Promoting Service Coordination in Maternal, Infant, and Early Childhood Home Visiting Programs.

The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program provides funding to states to promote health and development of at-risk expectant families and families with young children. MIECHV programs are required to coordinate services within a larger system of care; yet, little is known about state-level factors that support coordination. This study examined state-level supports and barriers for coordination of home visiting with other entities within the early childhood system of care. A Web-based survey was distributed in 2016 via e-mail to MIECHV administrators in all 50 states, 5 US territories, and the District of Columbia. The survey elicited information on 5 domains shown by theory and prior research to support coordination: MIECHV leadership, state leadership, shared goals across sectors, data systems, and finance. Respondents also rated their perceptions of state-level coordination. Forty-two (75%) of the MIECHV administrators participated in the survey. States and territories varied widely within and across the 5 domains of support for coordination. MIECHV leadership was an area of relative strength, whereas data systems and finance showed the most room for improvement. State leadership and shared goals were associated with stronger perceptions of state-level coordination. The findings indicate opportunities for shared learning among states to enhance coordination infrastructure. Such efforts should include multiple stakeholder perspectives and consideration of local and organizational contexts. This work could be facilitated using the service coordination toolkit developed as part of this project.

Recommended care and care adherence following a diagnosis of Lynch syndrome: a mixed-methods study

BackgroundLynch syndrome (LS) is the most common hereditary colorectal cancer (CRC) syndrome. This study assesses trends in diagnosis of LS and adherence to recommended LS-related care in a large integrated healthcare organization (~ 575,000 members).MethodsElectronic medical record (EMR) data (1999–2015) were examined to identify patients with a diagnosis of LS. We examined their LS-associated care recommendations and adherence to these recommendations. Qualitative patient and provider interviews were conducted with the aim of identifying opportunities for improved care delivery.ResultsWe identified 74 patients with a diagnosis of LS; 64% were diagnosed with a LS-related malignancy prior to their diagnosis of LS. The time to LS diagnosis following development of a LS-related cancer decreased over time: before 2009 11% of individuals received a diagnosis of LS within 1 year of developing a LS-related cancer compared to 83% after 2009 (p < 0.0001). Colonoscopy recommendations were documented in the EMR for almost all patients with LS (96%). Documentation of other recommendations for cancer surveillance was less commonly found. Overall, patient adherence to colonoscopy was high (M = 81.5%; SD = 32.7%), and adherence to other recommendations varied. To improve care coordination, patients and providers suggested providing automated reminder prompts for LS-related surveillance, adding a LS-specific diagnosis code, and providing guidelines for LS-related surveillance in the EMR.ConclusionsWe identified fewer than expected patients with LS in our large care system, indicating that there is still a diagnostic care gap. However, patients with LS were likely to receive and follow CRC surveillance recommendations. Recommendations for and adherence to extracolonic surveillance were variable. Improved care coordination and clearer documentation of the LS diagnosis is needed.

The micro-to-macro realities of antidepressant taking: Users’ experiences in the context of contested science and industry promotion

The macro landscape shaping antidepressant use is marked by uncertain and contested research and vigorous pharmaceutical promotion to doctors and (in the U.S.) patients. While prior studies have investigated antidepressant users’ firsthand experiences of the impacts of medication use on their lives and identities, these studies do not explicitly situate users’ experiences within the macro realities that shape the larger system of care. The aim of this Internet-based qualitative study was to advance a uniquely social work perspective on psychotropic medications by thematically examining the everyday experiences of antidepressant users and framing emergent themes within the broader macro context. The largest sample to date (n = 3243) of user reviews of four antidepressants (escitalopram, duloxetine, vilazodone, and vortioxetine) were downloaded from popular patient-reporting websites and analyzed line-by-line by two independent coders in a general inductive coding process. Antidepressant experiences were characterized by trial-and-error experimentation, limited relief, drug cocktails, uncertainty about causes of change, and unforeseen drug withdrawal challenges. Individual-level experiences are contextualized within the larger landscape of publication bias in clinical drug trials and persistent drug industry promotion of newer, costlier, and add-on drugs. Based on the profession’s systems perspective and social justice commitment, social workers should recognize how macro factors contextualize individual experience and strive to support users in cultivating more informed, empowering relationships with psychiatric drugs. Exploring the meaning of medications, validating users’ firsthand experiences, and monitoring changes throughout treatment and discontinuation are appropriate, critical roles that social workers should consider adopting.

Cognitive remediation in large systems of psychiatric care.

In 2014, the New York State Office of Mental Health set up a Cognitive Health Service that could be implemented throughout the state-operated system of care. This service was intended to broadly address cognitive health, to assure that the cognitive deficits commonly associated with psychiatric illnesses are recognized and addressed, and that cognitive health is embedded in the vocabulary of wellness. It involved creating a mechanism to train staff to recognize how cognitive health could be prioritized in treatment planning as well as implementing CR in state-operated adult outpatient psychiatry clinics. By 2017, CR was available at clinics serving people with serious mental illness in 13 of 16 adult Psychiatric Centers, located in rural and urban settings throughout New York state. The embedded quality assurance program evaluation tools indicated that CR was acceptable, sustainable, and effective. Cognitive remediation can be feasibly implemented in large systems of care that provide a multilevel system of supports, a training program that educates broadly about cognitive health and specifically about the delivery of CR, and embedded, ongoing program evaluation that is linked to staff supervision.

Development, Implementation, and Use of a Process to Promote Knowledge Translation in Rehabilitation

ObjectiveTo examine the use and effect of the Battery of Rehabilitation Assessments and Interventions on evidence-based practice (EBP) over 6 years. DesignSuccessive independent samples study. SettingLarge rehabilitation system. ParticipantsSuccessive samples of allied health clinicians (N=372) in 2009 (n=136), 2012 (n=115), and 2015 (n=121). InterventionsThe Battery of Rehabilitation Assessments and Interventions includes 2 components: (1) a process to synthesize, adapt, and make recommendations about the application of evidence; and (2) a process to implement the recommended practices in 3 levels of care. Main Outcome MeasuresTo assess the effect of the project, surveys on EBP perspectives, use, and barriers were conducted before Battery of Rehabilitation Assessments and Interventions implementation and 3 and 6 years after implementation. Questions about effect of the project on clinical practice were included 3 and 6 years postimplementation. ResultsSurvey data indicate the Battery of Rehabilitation Assessments and Interventions resulted in a significant increase in use of EBPs to make clinical decisions and justify care. As a result of the project, survey participants reported a substantial increase in use of outcome measures in 2012 (74%) and 2015 (91%) and evidence-based interventions in 2012 (62%) and 2015 (82%). In 2012, significant differences (P≤.01) in effect of the Battery of Rehabilitation Assessments and Interventions on practice were identified between therapists who were directly involved in the project and Interventions compared with uninvolved therapists. In 2015, no significant differences existed between involved and uninvolved therapists. ConclusionsAfter 6 years of sustained implementation efforts, the Battery of Rehabilitation Assessments and Interventions expedited the adoption of EBPs throughout a large system of care in rehabilitation.

APA Commentary on Ethics in Practice: An Additional Ethics Resource

APA Commentary on Ethics in Practice: An Additional Ethics Resource

A collaborative outcome resource network (ACORN): Tools for increasing the value of psychotherapy.

The authors describe a collaborative outcomes resource network (ACORN) and the suite of measurement and decision support tools (ACORN Toolkit) that have emerged from this collaboration for the purpose of providing clinical feedback to therapists. The ACORN Toolkit is most accurately described as a comprehensive clinical information system designed to increase the value of mental health services across large systems of care. It was built to integrate large datasets from multiple sources including outcome data, client demographics and diagnostic data, therapist credentialing information, pharmacy data, and service claims data. For the limited purposes of this article, the authors focus on the ACORN Toolkit for measuring and how it has contributed to improving outcomes in psychotherapy. Implications to current practice and future training are provided.

Delivering Mental Health Services to OEF/OIF Veterans

Veterans Health Administration (VHA) mental health (MH) professionals are providing care to increasing numbers of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). This study aimed to describe MH clinicians' views of OEF/OIF veteran needs and how providers meet those needs within a large system of care. Qualitative research methodology, specifically qualitative description, was used to explore VHA MH clinicians' experiences providing MH services to OEF/OIF veterans. Thirteen VA MH providers participated in semistructured interviews, which included questions regarding the following areas: psychiatric needs of OEF/OIF veterans; collaboration and referral; needs and resources; and the personal/professional impact of providing services to this cohort. Themes emerged which highlighted complex challenges faced by OEF/OIF veterans, barriers associated with matching the unique needs of these veterans with existing treatments, and the challenges and rewards associated with providing care to members of this population. Capturing provider perspectives within MH services suggest potential areas for innovation aimed at providing patient-centered care to this cohort of veterans. Results may also inform future work aimed at meeting the needs of both OEF/OIF veterans and MH providers.

It’s getting better all the time? Using secular trends to understand the impact of neurocritical care

It’s getting better all the time? Using secular trends to understand the impact of neurocritical care

State of Oncology Practice

Over the past couple of years there has been a lot of discussion about the structure of practice. All of us are familiar with the classic practice setting: a physician(s), two groups of nurses (clinical and infusion room), and two groups of business office employees (front and back office). A core principle supporting this structure is that all patient care is anchored in the physician's hands. If a decision is to be made, a form signed, or a patient seen, it will come to the physician in some form. Nursing is integral to practice, yet physicians have, as a rule, been hesitant to cede authority in the clinical realm of practice. In this issue, Towle et al present information about the benefits of integrating nonphysician practitioners into oncology practices. Many motivators prompted this evaluation. Workforce issues loom for our profession, and we must identify better models of practice to deal with the tsunami of demand that accompanies our aging population. Patients demand greater access to care, and regulators press for more measures of quality and efficiency. Oncologists cannot meet these demands if we cling to our current model of care. To effectively change the model of care will require these steps and more. Many practices are beginning to look at a model that is taking hold in primary care: the patient-centered medical home. This model structures practice to serve core needs of patients, recognizing that the only way to provide greater access to care and to coordinate care between multiple providers is for a practice to be team based and to be integrated into a larger system of care. The operational meaning of these phrases is likely a subject for great discussion, but one aspect of this is that physicians are no longer the center of the clinical universe. All team members must practice to the greatest extent of their training and competence, and we must let them. Implementing these principles transforms practice. Perspectives on these changes from nurse practitioners and physicians assistants are included in this issue of JOP. In addition, in Journal of Clinical Oncology, an editorial by Bajorin and Hanley underlines the necessity for oncologists to embrace a team-based clinical environment.1 Challenges in nonphysician practitioner training and structure exist, but my suspicion is that our profession's internal ethic of control is the greatest barrier to practice transformation. This issue and an upcoming November supplement feature articles that provide insight on the structure and financial health of oncology practice. This special series is anchored by three manuscripts. In addition to the ASCO Workforce contribution, two articles by Towle and Barr present a wealth of data about the financial underpinning of practice.2 These articles, and accompanying commentaries by Blayney and Eagle (both in this issue) and Hoverman (in the supplement3), are mandatory reading, as are articles by Kolodziej et al and Gonzalez et al that present sobering information about costs and business practices. We know that the best oncology care is given close to home, and most oncology care is provided in community-based private practices. How are these sites of service to be preserved in the face of these new realities? Many efforts are underway to transform our practices to different models of care. Essential to these efforts is enhancing the roles of team members in our offices and integrating our practices into the surrounding medical communities. This issue also features perspectives on recent work published in JCO. Villani provides a perspective on a review by Moy et al4 that addressed how federal health care legislation affects health care disparities. Also included is a perspective on a recently published ASCO guideline update re-examining the use of chemotherapy sensitivity and resistance assays.5 The reader will find other topics of interest in this issue and the November supplement. The editors hope that the information presented is challenging, and we seek feedback and suggestions concerning JOP. Please submit comments to gro.ocsa@ksedsrotidepoj.

Pharmaceutical policies: effects of restrictions on reimbursement.

Public policy makers and benefit plan managers need to restrain rising pharmaceutical drug costs while preserving access and optimizing health benefits. To determine the effects of a pharmaceutical policy restricting the reimbursement of selected medications on drug use, health care utilization, health outcomes and costs (expenditures). We searched the 14 major bibliographic databases and websites (to January 2009). Included were studies of pharmaceutical policies that restrict coverage and reimbursement of selected drugs or drug classes, often using additional patient specific information related to health status or need. We included randomised controlled trials, non-randomised controlled trials, interrupted time series (ITS) analyses, repeated measures studies and controlled before-after studies set in large care systems or jurisdictions. Two authors independently extracted data and assessed study limitations. Quantitative re-analysis of time series data was undertaken for studies with sufficient data. We included 29 ITS analyses (12 were controlled) investigating policies targeting 11 drug classes for restriction. Participants were most often senior citizens or low income adult populations, or both, in publically subsidized or administered pharmaceutical benefit plans. Impact of policies varied by drug class and whether restrictions were implemented or relaxed. When policies targeted gastric-acid suppressant and non-steroidal anti-inflammatory drug classes, decreased drug use and substantial savings on drugs occurred immediately and for up to two years afterwards, with no increase in the use of other health services (6 studies). Targeting second generation antipsychotic drugs increased treatment discontinuity and the use of other health services without reducing overall drug expenditures (2 studies). Relaxing restrictions for reimbursement of antihypertensives and statins increased appropriate use and decreased overall drug expenditures. Two studies which measured health outcomes directly were inconclusive. Implementing restrictions to coverage and reimbursement of selected medications can decrease third-party drug spending without increasing the use of other health services (6 studies). Relaxing reimbursement rules for drugs used for secondary prevention can also remove barriers to access. Policy design, however, needs to be based on research quantifying the harm and benefit profiles of target and alternative drugs to avoid unwanted health system and health effects. Health impact evaluation should be conducted where drugs are not interchangeable. Impacts on health equity, relating to the fair and just distribution of health benefits in society (sustainable access to publically financed drug benefits for seniors and low income populations, for example), also require explicit measurement.

The Impact of Comorbid Chronic Conditions on Diabetes Care

Effective diabetes management often presents enormous challenges. Not surprisingly, clinicians and patients alike can be overwhelmed by the need to address comorbid chronic conditions in addition to patients’ diabetes-specific treatment goals. Ignoring concurrent disease management, however, can lead to ineffective control of diabetes-specific risk factors and may miss opportunities to improve patients’ functioning, quality of life, and mortality risk. Other chronic conditions are common among people with diabetes and account for much of the morbidity these patients face. According to the Medical Expenditure Panel Survey, most adults with diabetes have at least one comorbid chronic disease (1) and as many as 40% have at least three (2,3). The increasing prevalence of multimorbidity among older diabetic adults is at least in part an unintended consequence of our success in improving diabetes treatment quality. Improvements in HbA1c (A1C) monitoring and glycemic control have been documented in several large systems of care (4–7). More widespread use of treatments such as ACE inhibitors and aspirin have decreased patients’ risk of cardiovascular death (8–10). Diabetic patients are living longer, and like all Americans, this increases their chance of acquiring one of the many chronic diseases associated with aging. Other more troubling trends have conspired to increase the impact of multimorbidity on diabetes management. In many health care systems, providers see patients during brief office visits and are overwhelmed by the number of health maintenance activities recommended by guidelines and quality monitoring agencies (11,12). When diabetic patients have multiple chronic conditions, screening, counseling, and treatment needs can far exceed the time available for patient-provider visits. Health problems that used to be treated in inpatient settings are increasingly managed within outpatient care, further straining providers’ resources for addressing diabetes-specific management goals (13). With inadequate health system support and …