Kathleen Sherrieb

Improved Outcomes Associated With Medical Home Implementation in Pediatric Primary Care

OBJECTIVE: The medical home model with its emphasis on planned care, care coordination, family-centered approaches, and quality provides an attractive concept construct for primary care redesign. Studies of medical home components have shown increased quality and reduced costs, but the medical home model as a whole has not been studied systematically. This study tested the hypothesis that increased medical homeness in primary care practice is associated with decreased utilization of health services and increased patient satisfaction. METHODS: Forty-three primary care practices were identified through 7 health plans in 5 states. Using the Medical Home Index (MHI), each practices implementation of medical home concepts “medical homeness” was measured. Health plans provided the previous years utilization data for children with 6 chronic conditions. The plans identified 42 children in each practice with these chronic conditions and surveyed their families regarding satisfaction with care and burden of illness. RESULTS: Higher MHI scores and higher subdomain scores for organizational capacity, care coordination, and chronic-condition management were associated with significantly fewer hospitalizations. Higher chronic-condition management scores were associated with lower emergency department use. Family survey data yielded no recognizable trends with respect to the medical home measurement. CONCLUSIONS: Developing an evidence base for the value of the primary care medical home has importance for providers, payers, policy makers, and consumers. Reducing hospitalizations through enhanced primary care provides a potential case for new reimbursement strategies supporting medical home services such as care coordination. Larger-scale studies are needed to further develop/examine these relationships.

Prevalence and Consequences of Disaster-Related Illness and Injury From Hurricane Ike

OBJECTIVE To explore the extent to which disasters may be a source of injury and disability in community populations, we examined the prevalence and short-term consequences of disaster-related illness and injury for distress, disability, and perceived needs for care. DESIGN A random population survey was conducted 2-6 months after Hurricane Ike struck Galveston Bay on September 13, 2008. PARTICIPANTS The sample was composed of 658 adults representative of Galveston and Chambers Counties, Texas. RESULTS The prevalences of personal injury (4%) and household illness (16%) indicated that approximately 7,700 adults in the two-county area were injured, and another 31,500 adults experienced household-level illness. Risk for injury/illness increased with area damage and decreased with evacuation. In bivariate tests, injury or illness or both were related to all outcome measures. In multivariate analyses that controlled for co-occurring stressors representing trauma, loss, adversities, and community effects, injury or illness or both were associated with global stress, posttraumatic stress, dysfunction, days of disability, and perceived needs for care, but not with depression or anxiety. CONCLUSIONS The associations of injury with distress and disability suggest that community programs should reach out to injured persons for early mental health and functional assessments and, where indicated, intervene in ways that reduce further disability and need for complex rehabilitative services. The results also point to the potential effectiveness of evacuation incentives with regard to the prevention of disaster-related injury and disability.

Resilience and Mental Health: Community resilience: concepts, assessment, and implications for intervention

Introduction Although stress research has emphasized individual well-being, many types of stress are experienced collectively: the events bring harm, pain, and loss to large numbers of people simultaneously. Natural disasters, terrorist attacks, war, political oppression, epidemics, and economic recessions happen to whole communities and, sometimes, whole societies. This is not to say that all exposed individuals experience the event identically; in a disaster, one person may lose a loved one, while another loses a home, and another only a few possessions. Nor is this to say that all exposed individuals respond identically; a person’s psychological, social, and material resources powerfully shape his or her capacity to cope and function effectively. When stress pervades the community, however, these factors tell only part of the story. To have an ecologically valid understanding of mass trauma, we must recognize that survivors are connected and dependent upon one another’s coping strategies. Their attributions and actions reflect a host of social influences, social comparisons, and emergent norms. They help each other but also compete for scarce resources. Household preparedness is vital, but one household can no more prepare for disaster than it could, on its own, protect itself from crime or disease, educate its children, or keep the roads safe. Consequently, an individual’s resilience is inextricably linked to the community’s ability to prepare for, respond to, and adapt to adverse conditions. Simply put, when problems are shared, so must be solutions. In recognition of such interdependencies, “community resilience” has emerged as a key concept for disaster readiness, although by no means limited to this one goal (Norris et al., 2008). This chapter will explore the concept of community resilience in some depth. Broadly, the chapter is organized into four sections. The first section provides our perspective on the meaning of resilience, including definitions that work across levels of analysis (individual, family, organization, community, society). The second section describes the adaptive capacities theorized to yield community resilience. This is followed by an outline of measurement strategies and challenges in assessing capacities, including some of our own pilot work. The concluding section makes recommendations for intervention and raises issues that need to be addressed in future research.

Public Health Consequences of Terrorism on Maternal–Child Health in New York City and Madrid

Past research provides evidence for trajectories of health and wellness among individuals following disasters that follow specific pathways of resilience, resistance, recovery, or continued dysfunction. These individual responses are influenced by event type and pre-event capacities. This study was designed to utilize the trajectories of health model to determine if it translates to population health. We identified terrorist attacks that could potentially impact population health rather than only selected individuals within the areas of the attacks. We chose to examine a time series of population birth outcomes before and after the terrorist events of the New York City (NYC) World Trade Center (WTC) attacks of 2001 and the Madrid, Spain train bombings of 2004 to determine if the events affected maternal–child health of those cities and, if so, for how long. For percentages of low birth weight (LBW) and preterm births, we found no significant effects from the WTC attacks in NYC and transient but significant effects on rates of LBW and preterm births following the bombings in Madrid. We did find a significant positive and sustained effect on infant mortality rate in NYC following the WTC attacks but no similar effect in Madrid. There were no effects on any of the indicator variables in the comparison regions of New York state and the remainder of Spain. Thus, population maternal–health in New York and Madrid showed unique adverse effects after the terrorist attacks in those cities. Short-term effects on LBW and preterm birth rates in Madrid and long-term effects on infant mortality rates in NYC were found when quarterly data were analyzed from 1990 through 2008/2009. These findings raise questions about chronic changes in the population’s quality of life following catastrophic terrorist attacks. Public health should be monitored and interventions designed to address chronic stress, environmental, and socioeconomic threats beyond the acute aftermath of events.

Cultivating change door to door: Educational outreach to improve prescribing practices in rural veterans with posttraumatic stress disorder

BACKGROUND Clinical guidelines for the management of posttraumatic stress disorder (PTSD) recommend against the use of benzodiazepines. Benzodiazepines and PTSD are both associated with addiction-related risks. The Department of Veterans Affairs (VA) prescribing trends show continued use of benzodiazepines and polysedative use in veterans with PTSD, particularly in rural areas. The authors examine the use of an educational intervention to improve pharmacologic management of veterans with PTSD in rural clinics. METHODS The VA Academic Detailing Service Informatics Toolset provides prescribing, demographic and risk factor data for veterans with PTSD treated at the White River Junction VA Medical Center (WRJ VA) and affiliated rural clinics in Vermont and New Hampshire. Individualized academic detailing visits were provided to clinicians identified by the informatics tool with the aim of increasing guideline-concordant care. Other educational efforts included traditional, didactic group education on evidence-based PTSD care and the development and dissemination of educational materials for clinicians and patients. Prescribing trends of benzodiazepines, off-label atypical antipsychotics, and prazosin were collected quarterly for 3 years (October 1, 2013, to September 30, 2016). RESULTS Prescribing rates of benzodiazepines during the educational intervention decreased from 13% to 9.3%. Use of off-label atypical antipsychotics, a class of medications not recommended for PTSD, stayed relatively flat at about 10%. Prescribing of prazosin, a medication recommended for treatment of trauma nightmares, increased from 9.8% to 14.3%. CONCLUSIONS Academic detailing and other educational programming appear to be effective for addressing gaps and lag in quality PTSD care and are associated with a positive trend of decreased benzodiazepine use. Efforts will continue, now with added focus on concurrent use of benzodiazepines and opioids and the use of off-label atypical antipsychotics in rural veterans with PTSD.

Community Clinicians and the Veterans Choice Program for PTSD Care: Understanding Provider Interest During Early Implementation

Background: In 2014, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program (VCP) to provide reimbursement for community-based care to eligible veterans. Inadequate networks of participating providers may impact the utility of VCP for veterans with posttraumatic stress disorder (PTSD), a complex condition occurring at lower frequency among civilians. Objectives: To compare characteristics and attitudes of community-based primary care and mental health providers reporting interest or no interest in VCP participation during early implementation; and to examine perceptions and experiences of VCP among “early adopters.” Research Design: Cross-sectional surveys with 2 samples: a stratified random sample of mental health and primary care prescribers and psychotherapists drawn from state licensing boards (Community Sample); and a stratified random sample of prescribers and psychotherapists identified as VCP-authorized providers (VCP-Authorized). Subjects: Five hundred fifty-three respondents in the Community Sample and 115 in the VCP-Authorized (total, n=668; 21.1% response). Measures: Surveys assessed provider and practice characteristics, attitudes to VA and VCP, and experiences and satisfaction with the VCP; an open-ended survey item assessed providers’ reasons for interest or lack of interest in VCP participation. Results: Few providers reported VCP participation during this period. Interest in VCP participation was associated across provider groups with factors including being a veteran and receiving VA reimbursement; currently providing treatment for PTSD was associated with interest in VCP participation among psychotherapists, but not prescribers. Conclusions: Developing networks of VCP providers to serve Veterans with PTSD is likely to require targeting more receptive provider groups, reducing barriers to participation, and more effectively communicating the value of VCP participation to providers.

Use of Guideline-Recommended Treatments for PTSD Among Community-Based Providers in Texas and Vermont: Implications for the Veterans Choice Program

Implementation of the Veterans Choice Program (VCP) allows Veterans to receive care paid for by the Department of Veterans Affairs (VA) in community settings. However, the quality of that care is unknown, particularly for complex conditions such as posttraumatic stress disorder (PTSD). A cross-sectional survey was conducted of 668 community primary care and mental health providers in Texas and Vermont to describe use of guideline-recommended treatments (GRTs) for PTSD. Relatively, few providers reported using guideline-recommended psychotherapy or prescribing practices. More than half of psychotherapists reported the use of at least one guideline-recommended psychotherapy for PTSD, but fewer reported the use of core treatment components, prior training in the GRT(s) they use, or adherence to a treatment manual. Suboptimal prescribing for PTSD patients was reported more commonly than optimal prescribing. Findings raise critical questions regarding how to ensure veterans seeking PTSD care in community settings receive psychotherapy and/or prescribing consistent with clinical practice guidelines.