Molly Finnerty

Fidelity Outcomes in the National Implementing Evidence-Based Practices Project

OBJECTIVE This article presents fidelity outcomes for five evidence-based practices that were implemented in routine public mental health settings in the National Implementing Evidence-Based Practices Project. METHODS Over a two-year period 53 community mental health centers across eight states implemented one of five evidence-based practices: supported employment, assertive community treatment, integrated dual disorders treatment, family psychoeducation, and illness management and recovery. An intervention model of practice dissemination guided the implementation. Each site used both human resources (consultant-trainers) and material resource (toolkits) to aid practice implementation and to facilitate organizational changes. External assessors rated fidelity to the evidence-based practice model every six months from baseline to two years. RESULTS More than half of the sites (29 of 53, or 55%) showed high-fidelity implementation at the end of two years. Significant differences in fidelity emerged by evidence-based practice. Supported employment and assertive community treatment had higher fidelity scores at baseline and across time. Illness management and recovery and integrated dual disorders treatment had lower scores on average throughout. In general, evidence-based practices showed an increase in fidelity from baseline to 12 months, with scores leveling off between 12 and 24 months. CONCLUSIONS Most mental health centers implemented these evidence-based practices with moderate to high fidelity. The critical time period for implementation was approximately 12 months, after which few gains were made, although sites sustained their attained levels of evidence-based practice fidelity for another year.

Scaling Up Evidence-Based Practices for Children and Families in New York State: Toward Evidence-based Policies on Implementation for State Mental Health Systems

Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the childrens mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.

The State Health Authority Yardstick (SHAY).

State mental health authorities have a leadership role in implementing evidence-based practices (EBPs), but few instruments are available to assess the impact of this role. We describe the development of the State Mental Health Authority Yardstick (SHAY), a behaviorally anchored instrument designed to assess state-level facilitating conditions associated with successful implementation of EBPs in community mental health centers. The SHAY assesses the SMHA role in seven domains: Planning, Financing, Training, Leadership, Policiesand Regulations, QualityImprovement, andStakeholders. Preliminary evidence from the National Evidence-Based Practices Project partially supports the construct and criterion-oriented validity of this instrument for rating state-level activities supporting or blocking the implementation of evidence-based practices.

Quality Concerns in Antipsychotic Prescribing for Youth: A Review of Treatment Guidelines

BACKGROUND Antipsychotic prescribing for youth has increased rapidly, is linked with serious health concerns, and lacks clear measures of quality for pediatric care. We reviewed treatment guidelines relevant to 7 quality concepts for appropriate use and management of youth on antipsychotics: 1) use in very young children, 2) multiple concurrent antipsychotics, 3) higher-than-recommended doses, 4) use without a primary indication, 5) access to psychosocial interventions, 6) metabolic screening, and 7) follow-up visits with a prescriber. METHODS We searched for clinical practice guidelines meeting the following criteria: developed or endorsed by a national body, published after 2000, and specific treatment recommendations made related to 1 or more of the 7 quality concepts. Sources included electronic databases, the American Academy of Child and Adolescent Psychiatry Web site, and stakeholder and expert advisory committee recommendations. Two raters reviewed the 11 guidelines identified, extracting treatment recommendations, including details that could support measure definitions, and ratings of strength of recommendation and evidence. RESULTS All 7 quality concepts were strongly endorsed by 1 or more guidelines, and 2 or more guidelines assigned their highest strength of recommendation ratings to 6 of the 7 concepts. Two guidelines rated evidence, providing high strength of evidence for 2 quality concepts: psychosocial interventions and metabolic monitoring. CONCLUSIONS Guidelines provide support for 7 quality concepts addressing antipsychotic prescribing for youth. However, guideline support is often based on strong clinical consensus rather than a robust evidence base.

The Effects of Prior Authorization Policies on Medicaid-Enrolled Children's Use of Antipsychotic Medications: Evidence from Two Mid-Atlantic States

OBJECTIVE The purpose of this study was to examine the impact of prior authorization policies on the receipt of antipsychotic medication for Medicaid-enrolled children. METHODS Using de-identified administrative Medicaid data from two large, neighboring, mid-Atlantic states from November 2007 through June 2011, we identified subjects <18 years of age using antipsychotics, from the broader group of children and adolescents receiving behavioral health services or any psychotropic medication. Prior authorization for antipsychotics was required for children in State A <6 years of age from September 2008, and for children <13 years of age from August 2009. No such prior authorizations existed in State B during that period. Filled prescriptions were identified in the data using national drug codes. Using a triple-difference strategy (using differences among the states, time periods, and differences in antidepressant prescribing rates among states over the same time periods), we examined the effect of the prior authorization policy on the rate at which antipsychotic prescriptions were filled for Medicaid-enrolled children and adolescents. RESULTS The impact of prior authorization policies on antipsychotic medication use varied by age: Among 6-12 year old children, the impact of the prior authorization policy on antipsychotic medication prescribing was a modest but statistically significant decrease of 0.47% after adjusting for other factors; there was no effect of the prior authorization among children 0-5 years. CONCLUSIONS Prior authorization policies had a modest but statistically significant effect on antipsychotic use in 6-12 year old children, but had no impact in younger children. Future research is needed to understand the utilization and clinical effects of prior authorization and other policies and interventions designed to influence antipsychotic use in children.

Forensic and Nonforensic Clients in Assertive Community Treatment: A Longitudinal Study

OBJECTIVE This study compared rates of arrest and incarceration, psychiatric hospitalization, homelessness, and discharge from assertive community treatment (ACT) programs for forensic and nonforensic clients in New York State and explored associated risk factors. METHODS Data were extracted from the New York State Office of Mental Healths Web-based outcome reporting system. ACT clients admitted between July 1, 2003, and June 30, 2007 (N=4,756), were divided into three groups by their forensic status at enrollment: recent (involvement in the past six months), remote (forensic involvement was more than six months prior), and no history. Client characteristics as of ACT enrollment and outcomes at one, two, and three years were compared over time. RESULTS Clients with forensic histories had a significantly higher ongoing risk of arrest or incarceration, and those with recent criminal justice involvement had a higher risk of homelessness and early discharge from ACT. Psychiatric hospitalization rates did not differ significantly across groups. Rates of all adverse outcomes were highest in the first year for all ACT clients, especially for those with a recent forensic history, and rates of psychiatric hospitalization, homelessness, and discharge declined over time for all clients. For all ACT clients, homelessness and problematic substance abuse at enrollment were significant risk factors for arrest or incarceration and for homelessness on three-year follow-up. CONCLUSIONS Clients with recent forensic histories were vulnerable to an array of adverse outcomes, particularly during their first year of ACT. This finding highlights the need for additional strategies to improve forensic and other outcomes for this high-risk population.

Long-term impact of web-based tools, leadership feedback, and policies on inpatient antipsychotic polypharmacy.

This column describes a series of interventions to decrease antipsychotic polypharmacy in the New York State Office of Mental Health (NYSOMH) network of psychiatric hospitals. Phase 1 consisted of implementation of the Psychiatric Services Clinical Knowledge Enhancement System (PSYCKES), a Web-based application supporting clinical decision making and quality improvement, and a policy requiring approval by NYSOMHs medical director to prescribe more than two antipsychotics per patient. In phase 2 hospital leaders received feedback from the office of the medical director identifying specific patients on polypharmacy. In phase 3, access to PSYCKES continued, but the prior-approval policy and feedback were discontinued. Polypharmacy decreased significantly during phase 1, from 16.9 to 9.7 inpatients per 1,000, and decreased further in phase 2, to 3.9 inpatients per 1,000. In phase 3 the prevalence of antipsychotic polypharmacy remained low at six-month follow-up (3.1 inpatients per 1,000), despite the ending of state-level oversight. On long-term follow-up, polypharmacy increased, eventually rising to 9.2 inpatients per 1,000 after 36 months, but remained well below baseline levels.

Reduction of Concurrent Antipsychotic Prescribing Practices Through the Use of PSYCKES

The New York State Office of Mental Health has implemented the browser based Psychiatric Clinical Knowledge Enhancement System (PSYCKES) medication application throughout its inpatient system of care. PSYCKES provides detailed current medication regimens and histories, as well as medication best practices reports at the patient, psychiatrist, ward, and facility levels. South Beach Psychiatric Center (SBPC) has made specific use of a best practices report which details proportions of caseloads and number of patients on two or more concurrent antipsychotic medications. Psychiatrists received extensive application and desktop support and individual and group training was conducted. PSYCKES current and historical medication regimens were reviewed for individual cases and best practices reports were used in psychiatry supervision from January 2004 to March 2005. SBPC psychiatrists achieved marked reductions in the proportions of their caseloads on two or more concurrent antipsychotics. Although we cannot impute causality from this pre–post implementation design, the results of this evaluation suggest that the use of PSYCKES was effective in reducing such regimens for inpatients.

Validation of a claims-based antipsychotic polypharmacy measure†

Given the metabolic and neurologic side effects of antipsychotics and concerns about the increased risks associated with concomitant use, antipsychotic polypharmacy is a quality concern. This study assessed the operating characteristics of a Medicaid claims‐based measure of antipsychotic polypharmacy.

Towards a Cultural Adaptation of Family Psychoeducation: Findings from Three Latino Focus Groups

This study was undertaken among Latinos receiving treatment from a community mental health center in New York City. The primary mental health concern was schizophrenia. We conducted three focus groups and present the viewpoints of consumers, family members, and providers. Using qualitative content analysis we identified four predominant categories: (1) the importance of family ties; (2) stigma about mental illness; (3) respect and trust in interpersonal relationships; and (4) facilitators and barriers to implementing Family Psychoeducation. Analysis of transcripts revealed specific subthemes for each category. Implications for imparting culturally sensitive material into mental health services for Latinos are discussed.