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Budget impact and sustainability of medical care management for persons with serious mental illnesses.

ABSTRACT: The authors assessed the 2-year outcomes, costs, and financial sustainability of a medical care management intervention for community mental health settings.A total of 407 psychiatric outpatients with serious mental illnesses were randomly assigned to usual care or to a medical care manager who provided care coordination and education. Two-year follow-up chart reviews and interviews assessed quality and outcomes of care, as well as costs from both the health system and managerial perspectives.Sustained improvements were observed in the intervention group in quality of primary care preventive services, quality of cardiometabolic care, and mental health-related quality of life. From a health system perspective, by year 2, the mean per-patient total costs for the intervention group were $932 (95% CI=-1,973 to 102) less than for the usual care group, with a 92.3% probability that the program was associated with lower costs than usual care. From the community mental health center perspective, the program would break even (i.e., revenues would cover setup costs) if 58% or more of clients had Medicaid or another form of insurance. Given that only 40.5% of clients in this study had Medicaid, the program was not sustainable after grant funding ended.The positive long-term outcomes and favorable cost profile provide evidence of the potential value of this model. However, the discrepancy between health system and managerial cost perspectives limited the program's financial sustainability. With anticipated insurance expansions under health reform, there is likely to be a stronger business case for safety net organizations considering implementing evidence-based interventions such as the one examined in this study.

SUBMITTER: Druss BG

PROVIDER: S-EPMC3775649 | biostudies-literature | 2011 Nov

REPOSITORIES: biostudies-literature

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Budget impact and sustainability of medical care management for persons with serious mental illnesses.

Druss Benjamin G BG von Esenwein Silke A SA Compton Michael T MT Zhao Liping L Leslie Douglas L DL

The American journal of psychiatry 20110615 11

<h4>Objective</h4>The authors assessed the 2-year outcomes, costs, and financial sustainability of a medical care management intervention for community mental health settings.<h4>Method</h4>A total of 407 psychiatric outpatients with serious mental illnesses were randomly assigned to usual care or to a medical care manager who provided care coordination and education. Two-year follow-up chart reviews and interviews assessed quality and outcomes of care, as well as costs from both the health syst ...[more]

PMID: 21676993

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Project description:The serious mental illnesses schizophrenia, schizoaffective disorder, and bipolar disorder are complex conditions affecting 1% to 4% of the population. Individuals with serious mental illnesses express interest in genetic counseling, an intervention showing promise for increasing patient knowledge and adaptation. This trial aimed to evaluate the effects of genetic counseling for people with serious mental illnesses as compared to an educational intervention or wait list.A pilot 3-arm (each n = 40; genetic counseling, a control intervention involving an educational booklet, or wait list), parallel-group, randomized clinical trial was conducted from September 2008 through November 2011 in Vancouver, Canada. Participants with schizophrenia, bipolar disorder, or schizoaffective disorder (DSM-IV) completed outcome measures assessing knowledge, risk perception, internalized stigma, and perceived control over illness at baseline and 1-month follow-up. The Brief Symptom Inventory was administered to control for current symptoms. Analyses included linear mixed-effects models and ?(2) tests.Knowledge increased for genetic counseling/educational booklet compared to wait list at follow-up (LRT1 = 19.33, Holm-adjusted P = .0003, R(2)LMM(m) = 0.17). Risk perception accuracy increased at follow-up for genetic counseling compared to wait list (Yates continuity corrected ?(2)1 = 9.1, Bonferroni P = .003) and educational booklet (Yates continuity corrected ?(2)1 = 8.2, Bonferroni P = .004). There were no significant differences between groups for stigma or perceived control scores.Genetic counseling and the educational booklet improved knowledge, and genetic counseling, but not the educational booklet, improved risk perception accuracy for this population. The impact of genetic counseling on internalized stigma and perceived control is worth further investigation. Genetic counseling should be considered for patients with serious mental illnesses.ClinicalTrials.gov identifier: NCT00713804.

Project description:BACKGROUND:Medication used for acute aggression in psychiatry must have rapid onset of effect, low frequency of administration and low levels of adverse effects. Zuclopenthixol acetate is said to have these properties. OBJECTIVES:To estimate the clinical effects of zuclopenthixol acetate for the management of acute aggression or violence thought to be due to serious mental illnesses, in comparison to other drugs used to treat similar conditions. SEARCH METHODS:We searched the Cochrane Schizophrenia's Group Trials Register (July 2011). We supplemented this by citation searching and personal contact with authors and relevant pharmaceutical companies. SELECTION CRITERIA:All randomised clinical trials involving people thought to have serious mental illnesses comparing zuclopenthixol acetate with other drugs. DATA COLLECTION AND ANALYSIS:Two review authors extracted and cross-checked data independently. We calculated fixed-effect relative risks (RR) and 95% confidence intervals (CI) for dichotomous data. We analysed by intention-to-treat. We used mean differences (MD) for continuous variables. MAIN RESULTS:We found no data for the primary outcome, tranquillisation. Compared with haloperidol, zuclopenthixol acetate was no more sedating at two hours (n = 40, 1 RCT, RR 0.60, 95% CI 0.27 to 1.34). People given zuclopenthixol acetate were not at reduced risk of being given supplementary antipsychotics (n = 134, 3 RCTs, RR 1.49, 95% CI 0.97 to 2.30) although additional use of benzodiazepines was less (n = 50, 1 RCT, RR 0.03, 95% CI 0.00 to 0.47). People given zuclopenthixol acetate had fewer injections over seven days compared with those allocated to haloperidol IM (n = 70, 1 RCT, RR 0.39, 95% CI 0.18 to 0.84, NNT 4, CI 3 to 14). We found no data on more episodes of aggression or harm to self or others. One trial (n = 148) reported no significant difference in adverse effects for people receiving zuclopenthixol acetate compared with those allocated haloperidol at one, three and six days (RR 0.74, 95% CI 0.43 to 1.27). Compared with haloperidol or clotiapine, people allocated zuclopenthixol did not seem to be at more risk of a range of movement disorders (< 20%). Three studies found no difference in the proportion of people getting blurred vision/dry mouth (n = 192, 2 RCTs, RR at 24 hours 0.90, 95% CI 0.48 to 1.70). Similarly, dizziness was equally infrequent for those allocated zuclopenthixol acetate compared with haloperidol (n = 192, 2 RCTs, RR at 24 hours 1.15, 95% CI 0.46 to 2.88). There was no difference between treatments for leaving the study before completion (n = 522, RR 0.85, 95% CI 0.31 to 2.31). One study reported no difference in adverse effects and outcome scores, when high dose (50-100 mg/injection) zuclopenthixol acetate was compared with low dose (25-50 mg/injection) zuclopenthixol acetate. AUTHORS' CONCLUSIONS:Recommendations on the use of zuclopenthixol acetate for the management of psychiatric emergencies in preference to 'standard' treatment have to be viewed with caution. Most of the small trials present important methodological flaws and findings are poorly reported. This review did not find any suggestion that zuclopenthixol acetate is more or less effective in controlling aggressive acute psychosis, or in preventing adverse effects than intramuscular haloperidol, and neither seemed to have a rapid onset of action. Use of zuclopenthixol acetate may result in less numerous coercive injections and low doses of the drug may be as effective as higher doses. Well-conducted pragmatic randomised controlled trials are needed.

Project description:BackgroundDigital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses.ObjectiveThis narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses.MethodsA narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance.ResultsResults indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features.ConclusionsMore research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.

Project description:IntroductionPatients with mental and physical health conditions are complex to treat and often use multiple medications. It is unclear how adherence to one medication predicts adherence to others. A predictive relationship could permit less expensive adherence monitoring if overall adherence could be predicted through tracking a single medication.MethodsTo test this hypothesis, we examined whether patients with multiple mental and physical illnesses have similar adherence trajectories across medications. Specifically, we conducted a retrospective cohort analysis using health insurance claims data for enrollees who were diagnosed with a serious mental illness, initiated an atypical antipsychotic, as well as an SSRI (to treat serious mental illness), biguanides (to treat type 2 diabetes), or an ACE inhibitor (to treat hypertension). Using group-based trajectory modeling, we estimated adherence patterns based on monthly estimates of the proportion of days covered with each medication. We measured the predictive value of the atypical antipsychotic trajectories to adherence predictions based on patient characteristics and assessed their relative strength with the R-squared goodness of fit metric.ResultsWithin our sample of 431,591 patients, four trajectory groups were observed: non-adherent, gradual discontinuation, stop-start, and adherent. The accuracy of atypical antipsychotic adherence for predicting adherence to ACE inhibitors, biguanides, and SSRIs was 44.5, 44.5, and 49.6%, respectively (all p < 0.001 vs. random). We also found that information on patient adherence patterns to atypical antipsychotics was a better predictor of patient adherence to these three medications than would be the case using patient demographic and clinical characteristics alone.ConclusionAmong patients with multiple chronic mental and physical illnesses, patterns of atypical antipsychotic adherence were useful predictors of adherence patterns to a patient's adherence to ACE inhibitors, biguanides, and SSRIs.FundingOtsuka Pharmaceutical Development & Commercialization, Inc.

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Budget impact and sustainability of medical care management for persons with serious mental illnesses.

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Budget impact and sustainability of medical care management for persons with serious mental illnesses.

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