Elizabeth J. Gifford

Provider-Level Effects on Psychiatric Inpatient Length of Stay for Youth With Mental Health and Substance Abuse Disorders

Objective:Previous research on inpatient care for children and adolescents with emotional or behavioral problems indicates that patient-level factors predict length of stay (LOS) poorly. This analysis examines whether patient-level factors are poor predictors of LOS, because LOS is primarily determined by facilities rather patients. Study Design:This study uses Tennessee Medicaid claims data from 1996 to 2001. The data include information on 14,162 observations related to 8400 patients (age 12–21) from 163 hospitals. We estimate log LOS using a cross-classified model. Covariates include admission-level characteristics (age, diagnosis, qualification for Medicaid, year), patient-level characteristics (gender, race), and facility characteristics (facility type). Principle Findings:Our results suggest that variation in LOS is attributable to facility-level factors (51%), time-invariance patient-level factors (5%), factors that vary across admissions (42%), and a correlation between patient-level and facility-level factors (5%). Conclusions:About half of the variation in LOS is explained by facility-level factors. Given the vulnerable nature of youth who are in need of inpatient psychiatric care, it may be particularly important to monitor provider-level processes and outcomes. Measuring facility or provider level quality is complicated because of difficulties in adjusting for case-mix severity across providers. The methodology presented here represents a general framework that can be widely used in health services research. Potential applications include broadening models of utilization to simultaneously include patient, provider, geographic and community level variations, as well as provider profiling.

How does family drug treatment court participation affect child welfare outcomes

Parental substance use is a risk factor for child maltreatment. Family drug treatment courts (FDTCs) have emerged in the United States as a policy option to treat the underlying condition and promote family preservation. This study examines the effectiveness of FDTCs in North Carolina on child welfare outcomes. Data come from North Carolina records from child protection services, court system, and birth records. Three types of parental participation in a FDTC are considered: referral, enrolling, and completing an FDTC. The sample includes 566 children who were placed into foster care and whose parents participated in a FDTC program. Findings indicate that children of parents who were referred but did not enroll or who enrolled but did not complete had longer stays in foster care than children of completers. Reunification rates for children of completers were also higher. Outcomes for children in the referred and enrolled groups did not differ in the multivariate analyses. While effective substance use treatment services for parents may help preserve families, future research should examine factors for improving participation and completion rates as well as factors involved in scaling programs so that more families are served.

The effects of participation level on recidivism: a study of drug treatment courts using propensity score matching.

BackgroundEmpirical evidence has suggested that drug treatment courts (DTCs) reduce re-arrest rates. However, DTC program completion rates are low and little is known about the effectiveness of lower levels of program participation.ObjectivesWe examined how DTC program referral, enrollment without completion, and completion, affected re-arrest rates during a two-year follow-up.Research designWe used statewide North Carolina data from criminal courts merged with DTC data. Propensity score matching was used to select comparison groups based on demographic characteristics, criminal histories, and drug of choice (when available). Average treatment effects on the treated were computed.MeasuresDTC participation levels included referral without enrollment, (n = 2,174), enrollment without completion (n = 954), and completion (n = 747). Recidivism measured as re-arrest on a substance-related charge, on a violent offense charge not involving an allegation of substance abuse, and on any charge (excluding infractions) was examined by felony and misdemeanor status during a two-year follow-up period.ResultsRe-arrest rates were high, 53–76 percent. In general, re-arrest rates were similar for individuals who were referred but who did not enroll and a matched comparison group consisting of individuals who were not referred. In contrast, enrollees who did not complete had lower re-arrest rates than a matched group of individuals who were referred but did not enroll, for arrests on any charge, on any felony charge, and on substance-related charges (felonies and misdemeanors). Finally, relative to persons who enrolled but did not complete, those who completed had lower re-arrest rates on any charge, any felony charge, any misdemeanor charge, any substance-related charge, any substance-related misdemeanor or felony charge, and any violent felony charge.ConclusionsEnrolling in a DTC, even without completing, reduced re-arrest rates. Given the generally low DTC completion rate, this finding implies that only examining effects of completion underestimates the benefits of DTC programs.

Risk factors for biopsy‐proven advanced non‐alcoholic fatty liver disease in the Veterans Health Administration

With its increasing incidence, nonalcoholic fatty liver disease (NAFLD) is of particular concern in the Veterans Health Administration (VHA).

Pairing nurses and social workers in schools: North Carolina's school-based Child and Family Support Teams.

When children are struggling in school, underlying causes often include physical or behavioral health problems, poverty, abuse, and/or neglect. Children’s poor physical health status has been linked to deficits in memory and reading ability.1 Children with behavioral problems are much more likely than others to have lower grades, miss school, be suspended or expelled, and drop out.2–4 Access to needed health and human services is critical to vulnerable children’s success in school. Yet, need often does not predict use. Approximately, 7% of children overall have an unmet need for health care, with the poor, near poor, and uninsured being 3 times more likely than their peers to be underserved.5 Only about 1 in 5 children in need of mental health care receive services.6 Even available services are often fragmented, making it more difficult for families both to access and utilize them effectively. Increasingly, the federal government, child advocacy groups, and private funders are therefore encouraging any organization that identifies an at-risk child, to convene a team including representatives of all relevant agencies. These teams should include parents as full partners to identify both child and parent needs and to build service plans on strengths as well as needs.7 Given their primary role in children’s lives, schools are a logical base for such coordination. The current article describes an innovative effort in North Carolina to help at-risk children thrive academically and remain with their families: the school-based Child and Family Support Team Initiative (CFST). The following provides an overview of the program and a profile of the children served in the program’s first 2 years.

A Network Perspective on Dropout Prevention in Two Cities.

Purpose: This exploratory case study examines how school systems and other local organizations have been working within two major U.S. cities to improve high school graduation rates. Systematically assessing active interorganizational dropout prevention networks may reveal characteristics affecting communities’ capacity to support school completion. Research Method: This study included the local affiliates within two U.S. cities of national partners in a dropout prevention initiative. A survey and follow-up interview probed for each organization’s cooperation with the other local organizations. Social network analyses revealed how school superintendents’ offices and other local agencies cooperated, as well as which organizations were most central within each city’s dropout prevention network. Findings: School systems in both cities cooperated with the YMCA, Big Brothers Big Sisters, Boys and Girls Club, the mayor’s office, United Way, and Chamber of Commerce. Among the most central organizations in broader dropout prevention-related networks were the YMCA, Communities in Schools, mayor’s office, and the United Way. Implications for Research and Practice: An organizational network perspective can help school systems identify strategic opportunities to build local capacity for supporting youth. Working with key brokers may then offer a feasible way for schools to leverage local resources.

Intergenerational effects of parental substance-related convictions and adult drug treatment court participation on children's school performance.

This study examined the intergenerational effects of parental conviction of a substance-related charge on childrens academic performance and, conditional on a conviction, whether completion of an adult drug treatment court (DTC) program was associated with improved school performance. State administrative data from North Carolina courts, birth records, and school records were linked for 2005-2012. Math and reading end-of-grade test scores and absenteeism were examined for 5 groups of children, those with parents who: were not convicted on any criminal charge, were convicted on a substance-related charge and not referred by a court to a DTC, were referred to a DTC but did not enroll, enrolled in a DTC but did not complete, and completed a DTC program. Accounting for demographic and socioeconomic factors, the school performance of children whose parents were convicted of a substance-related offense was worse than that of children whose parents were not convicted on any charge. These differences were statistically significant but substantially reduced after controlling for socioeconomic characteristics; for example, mothers educational attainment. We found no evidence that parent participation in an adult DTC program led to improved school performance of their children. While the children of convicted parents fared worse on average, much--but not all--of this difference was attributed to socioeconomic factors, with the result that parental conviction remained a risk factor for poorer school performance. Even though adult DTCs have been shown to have other benefits, we could detect no intergenerational benefit in improved school performance of their children.

Do Specialty Courts Achieve Better Outcomes for Children in Foster Care than General Courts

Objective: This study assessed the effects of unified family and drug treatment courts (DTCs) on the resolution of cases involving foster care children and the resulting effects on school performance. Method: The first analytic step was to assess the impacts of presence of unified and DTCs in North Carolina counties on time children spent in foster care and the type of placement at exit from foster care. In the second step, the same data on foster care placements were merged with school records for youth in Grades 3–8 in public schools. The effect of children’s time in foster care and placement outcomes on school performance as measured by math and reading tests, grade retention, and attendance was assessed using child fixed-effects regression. Results: Children in counties with unified family courts experienced shorter foster care spells and higher rates of reunification with parents or primary caregivers. Shorter foster care spells translated into improved school performance measured by end-of-grade reading and math test scores. Adult DTCs were associated with lower probability of reunification with parents/primary caregivers. Conclusion: The shortened time in foster care implies an efficiency gain attributable to unified family courts, which translate into savings for the court system through the use of fewer resources. Children also benefit through shortened stays in temporary placements, which are related to some improved educational outcomes.

Parental Criminal Justice Involvement and Children's Involvement With Child Protective Services: Do Adult Drug Treatment Courts Prevent Child Maltreatment?

ABSTRACT Background: In light of evidence showing reduced criminal recidivism and cost savings, adult drug treatment courts have grown in popularity. However, the potential spillover benefits to family members are understudied. Objectives: To examine: (1) the overlap between parents who were convicted of a substance-related offense and their childrens involvement with child protective services (CPS); and (2) whether parental participation in an adult drug treatment court program reduces childrens risk for CPS involvement. Methods: Administrative data from North Carolina courts, birth records, and social services were linked at the child level. First, children of parents convicted of a substance-related offense were matched to (a) children of parents convicted of a nonsubstance-related offense and (b) those not convicted of any offense. Second, we compared children of parents who completed a DTC program with children of parents who were referred but did not enroll, who enrolled for <90 days but did not complete, and who enrolled for 90+ days but did not complete. Multivariate logistic regression was used to model group differences in the odds of being reported to CPS in the 1 to 3 years following parental criminal conviction or, alternatively, being referred to a DTC program. Results: Children of parents convicted of a substance-related offense were at greater risk of CPS involvement than children whose parents were not convicted of any charge, but DTC participation did not mitigate this risk. Conclusion/Importance: The role of specialty courts as a strategy for reducing childrens risk of maltreatment should be further explored.

Identifying Nonalcoholic Fatty Liver Disease Advanced Fibrosis in the Veterans Health Administration

BackgroundNonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Severe NAFLD with advanced fibrosis results in substantial morbidity and mortality. Associated with metabolic syndrome, NAFLD is often initially clinically silent, yet intensive lifestyle intervention with 7% or greater weight loss can improve or resolve NAFLD. Using a Veterans Health Administration (VHA) liver biopsy cohort, we evaluated simple noninvasive fibrosis scoring systems to identify NAFLD with advanced fibrosis (or severe disease) to assist providers.MethodsIn our retrospective study of a national VHA sample of patients with biopsy-proven NAFLD or normal liver (2005–2015), we segregated patients by fibrosis stage (0–4). Non-NAFLD liver disease was excluded. We evaluated the diagnostic accuracy of the NAFLD fibrosis score (NFS), fibrosis-4 calculator (FIB-4), aspartate aminotransferase-to-alanine aminotransferase ratio (AST/ALT ratio), AST-to-platelet ratio index (APRI), and body mass index, AST/ALT ratio, and diabetes (BARD) score by age groups.ResultsWe included 329 patients with well-defined liver histology (296 NAFLD and 33 normal controls without fibrosis), in which 92 (28%) had advanced (stage 3–4) fibrosis. Across all age groups, NFS and FIB-4 best predicted advanced fibrosis (NFS with 0.676 threshold: AUROC 0.71–0.76, LR + 2.30–22.05, OR 6.00–39.58; FIB-4 with 2.67 threshold: AUROC of 0.62–0.80, LR + 4.70–27.45, OR 16.34–59.65).ConclusionsWhile NFS and FIB-4 scores exhibit good diagnostic accuracy, FIB-4 is optimal in identifying NAFLD advanced fibrosis in the VHA. Easily implemented as a point-of-care clinical test, FIB-4 can be useful in directing patients that are most likely to have advanced fibrosis to GI/hepatology consultation and follow-up.