Bernadette Benjamin

Sheltered homeless children: their eligibility and unmet need for special education evaluations.

OBJECTIVES This study described the proportion of sheltered homeless children in Los Angeles, Calif, who were eligible for special education evaluations because of a probable behavioral disorder, learning disability, or mental retardation, and to explore their level of unmet need for special education services. METHODS This was a cross-sectional study of 118 parents and 169 children aged 6 through 12 years living in 18 emergency homeless family shelters in Los Angeles County, California. Parents and children were interviewed with standardized mental health and academic skill measures in English and Spanish. RESULTS Almost half (45%) of the children met criteria for a special education evaluation, yet less than one quarter (22%) had ever received special education testing or placement. The main point of contact for children with behavioral disorders and learning problems was the general health care sector. CONCLUSIONS School-aged sheltered homeless children have a high level of unmet need for special education evaluations, the first step toward accessing special education programs. Interventions for homeless children should include integration of services across special education, general health care, and housing service sectors.

Impact of a Primary Care Quality Improvement Intervention on Use of Psychotherapy for Depression

We examine the impact of the two Partners in Care (PIC) primary care quality improvement (QI) interventions on counseling services. The QI interventions aimed to increase service use, and thereby improve outcomes, and have been shown to indeed improve patient outcomes (e.g., K. B. Wells et al., 2000). But whether or not use of counseling services actually increased has not yet been examined. The QI interventions contained many overlapping elements; however, QI-Therapy emphasized cognitive–behavioral therapy, and QI-Meds emphasized medications and case management. QI-Therapy patients used more counseling than UC patients at 6 months, though increases were modest. Some treatment effects persisted until 12 months, but not beyond. QI-Therapy and QI-Meds patients reported more treatment overall (therapy or medication) than UC patients at 6 months, and this effect persisted in the QI-Meds clinics until 12 months. Treatment effects were more pronounced among those most in need. Despite high rates of referral to psychotherapy within the QI-Therapy clinics (81%), only a minority of patients actually attended a psychotherapy session within the study (30%). We discuss the uptake of therapy in this study as a way to inform future efforts at QI.

The Effects of Quality Improvement for Depression in Primary Care at Nine Years: Results from a Randomized, Controlled Group-Level Trial

OBJECTIVE To examine 9-year outcomes of implementation of short-term quality improvement (QI) programs for depression in primary care. DATA SOURCES Depressed primary care patients from six U.S. health care organizations. STUDY DESIGN Group-level, randomized controlled trial. DATA COLLECTION Patients were randomly assigned to short-term QI programs supporting education and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy); and usual care (UC). Of 1,088 eligible patients, 805 (74 percent) completed 9-year follow-up; results were extrapolated to 1,269 initially enrolled and living. Outcomes were psychological well-being (Mental Health Inventory, five-item version [MHI5]), unmet need, services use, and intermediate outcomes. PRINCIPAL FINDINGS At 9 years, there were no overall intervention status effects on MHI5 or unmet need (largest F (2,41)=2.34, p=.11), but relative to UC, QI-Meds worsened MHI5, reduced effectiveness of coping and among whites lowered tangible social support (smallest t(42)=2.02, p=.05). The interventions reduced outpatient visits and increased perceived barriers to care among whites, but reduced attitudinal barriers due to racial discrimination and other factors among minorities (smallest F (2,41)=3.89, p=.03). CONCLUSIONS Main intervention effects were over but the results suggest some unintended negative consequences at 9 years particularly for the medication-resource intervention and shifts to greater perceived barriers among whites yet reduced attitudinal barriers among minorities.

The cumulative effects of quality improvement for depression on outcome disparities over 9 years: results from a randomized, controlled group-level trial.

Background:Quality improvement (QI) programs for depression can improve outcomes of care and reduce outcome disparities; but cumulative effects on mental health outcome disparities have seldom been evaluated. Objective:To estimate cumulative effects over many years of short-term QI programs for depression in primary care on mental health outcome disparities, and to develop an interpretation for annualized, cumulative mental health outcome scores. Design:We conducted a group-level, randomized controlled trial in 6 US healthcare organizations. The QI programs supported provider and patient education in depression treatment and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy). Sites were selected to oversample minorities. Patients:Results were extrapolated to 1188 initially enrolled and living patients depressed at baseline. Main Outcome:Psychologic well-being (MHI-5) estimated as cumulative outcomes and outcome disparities (minority-whites) over 9 years, and annualized. Results:Across analyses there was a significant interaction of intervention status and ethnicity [lowest F(2,160) = 4.96, P = 0.008]. QI-therapy improved cumulative outcomes among minorities (mean, 37.92–44.29 MHI-5 points) and reduced outcome disparities for the whole sample relative to usual care (UC) (by mean, 39.44–59.01 MHI-5 points) and relative to QI-Meds (by mean, 53.90–74.41 MHI-5 points), lowest t(103) = 3.12, P = 0.002. By comparison, UC patients who lost a loved one in the year after baseline had lower psychologic well being by 6.18 MHI-5 scale points compared with similar UC patients without such a loss [t(15)=2.52, P = 0.02]. Conclusions:QI programs incorporating support for evidence-based psychotherapy offer an approach to substantially reduce cumulative outcome disparities for depressed primary care patients.

Patient, provider and hospital characteristics associated with inappropriate hospitalization.

To determine the relation between patient and provider characteristics and inappropriate hospital use, we examined adult nonpregnancy hospitalizations from a randomized trial of health insurance conducted in six sites in the United States. Appropriateness of inpatient treatment was based on medical record review; patient characteristics on sociodemographic, economic, and health status; and provider characteristics on descriptors of physician practice and hospital facilities. Twenty-seven percent of admissions attended by physicians licensed for more than 15 years were judged inappropriate, compared to 20 percent for younger physicians. Admissions were more likely to be inappropriate if the patient was female (27 percent compared with 18 percent). Controlling for patient and provider characteristics reduces but does not eliminate the differences in the appropriateness of inpatient care across the studys six sites. Differences in available provider and patient characteristics do not account for geographic differences in inappropriate hospitalization in this study.

The sensitivity of mental health care use and cost estimates to methods effects.

The authors determined the sensitivity of estimates of the use and cost of outpatient mental health care to two methods effects: the definition of a mental health visit and strategies for allocating mental health care costs. They use data from the Rand Health Insurance Study, which has a random sample of the nonaged noninstitutionalized civilian population in six United States sites. Estimates of the use of mental health specialists are insensitive to alternative methods. However, estimates of the use and cost of the mental health care delivered by nonpsychiatrist physicians (e.g., internists) are quite sensitive to methods effects. Nevertheless, the cost of care from nonpsychiatrist physicians is so low that the total cost of outpatient mental health care is not meaningfully affected by methods effects.

Quality of care for depressed elderly pre-post prospective payment system: differences in response across treatment settings.

We evaluated the quality of care for depressed elderly patients (n=2,746) hospitalized in general medical hospitals (n = 297) before or after implementation of Medicares Prospective Payment System, focusing on whether the response to time period differed for hospitals that in the post-PPS period had no psychiatric unit, an exempt psychiatric unit, or a nonexempt unit, and by ward placement within hospitals with psychiatric units. Quality of care increased over time, and for most measures of quality of care the level of improvement did not differ significantly across different types of hospitals or by ward placement. The intensity of use of therapeutic services, such as rehabilitation, occupation, or recreation therapy, increased over time, particularly in nonexempt psychiatric units and hospitals without psychiatric units, such that these locations caught up some over time in the level of use of these services to the level for exempt psychiatric units. Several outcomes of care improved over time, and the degree of improvement in the rate of inpatient medical and psychiatric complications and other outcomes was significantly greater for psychiatric units that were exempt post-PPS than for nonexempt treatment locations.

A comparison of the effects of sociodemographic factors and health status on use of outpatient mental health services in HMO and fee-for-service plans.

The authors compared the effects of age, sex, socioeconomic status, and mental and physical health status on the use of outpatient mental health services in one well-established health maintenance organization (HMO) and in fee-for-service plans. In the Seattle site of the Rand Health Insurance Study (HIS), families were randomly assigned to HMO or fee-for-service coverage. Adults incur much greater expense for outpatient mental health services than children in both an HMO and a fee-for-service plan with identical coverage (i.e., free care). However, the difference in use between adults and children is significantly greater for the fee-for-service plan than the HMO (P < 0.01). Similarly, education has significantly greater effects on use for the fee-for-service than the HMO plan. Increased income has a significant negative effect on use in both the HMO and fee-for-service plans. Mental and physical health status have similar large effects on use in both fee-for-service and HMO plans.

Homeless Children in Emergency Shelters: Need for Prereferral Intervention and Potential Eligibility for Special Education.

The purpose of this study was to describe the level of need for special education services for probable behavioral disorders (BD), learning disabilities (ID), and mental retardation (MR) among school-age homeless children living in shelters. Children living in emergency homeless shelters face the dual challenge of being at risk for BD and learning problems while having limited access to special education programs. From a county-wide sample of 18 out of 22 emergency homeless shelters in Los Angeles, 118 homeless parents were interviewed, and 169 children were tested for BD, LD, and MR using standardized screening instruments. Almost one half of sheltered homeless children (46%) screened positive for at least one disability requiring special education services, with BD being the most prominent (30%). Procedures to identify early need for special education services should be adapted to accommodate the transiency of school-age children living in homeless shelters.

Institutional and Economic Influences on Quality of Nursing Documentation

This study evaluates the quality of nursing documentation within the hospital record for a particularly vulnerable group of patients, the depressed aged. Specifically, the effects of prospective payment, unit type, hospital type, and nurse staffing levels on nursing documentation within hospital charts were assessed.