News and Notes

NASMHPD report highlights importance of state psychiatric hospitals: A total of 207 state-operated psychiatric hospitals exist nationwide, serving approximately 40,600 people at any given time. A new technical report from the National Association of State Mental Health Program Directors (NASMHPD) makes the advocacy case that state psychiatric hospitals are a vital part of the continuum of recovery services. The report does not advocate for increasing state hospitals or beds. Instead it makes several recommendations to ensure that state psychiatric hospitals are recovery oriented and integrated with a robust set of community services, emphasizing that changing the hospital culture is essential to providing effective care. To support the recommendations, the report describes the history of state psychiatric hospitals, from the early advocacy of Dorothea Dix to how these hospitals are now used; provides historical and current data on capacity and costs, including Medicaid’s role in financing state hospital care; and reviews the 1999 Olmstead Supreme Court decision and its impact. A separate section describes what the environment and culture of these hospitals should be, detailing the multiple ways that a recovery orientation should inform care. The report recommends that peer support specialists be included as equal members of the treatment team. The report’s recommendations are focused at four levels: the hospital facility level (service users, staff, and community providers), the state level (State Mental Health Authority), the federal level (through the work of NASMHPD), and NASMHPD’s own organizational level. The 61-page report, The Vital Role of State Psychiatric Hospitals, is available on the NASMHPD Web site (www.nasmhpd.org).

CHCS brief promotes integrated services in Medicaid ACOs: Medicaid programs in several states have created accountable care organizations (ACOs) to improve health care quality and control rising costs, particularly for high-need beneficiaries with complex health conditions. Medicaid programs have increasingly recognized the substantial impact that behavioral health disorders have on Medicaid beneficiaries with chronic general medical conditions. Average health care costs for this group are more than three times higher than for beneficiaries without a co-occurring behavioral disorder, and hospitalization rates are four times higher. An issue brief from the Center for Health Care Strategies (CHCS) outlines considerations to guide state Medicaid agencies in successfully integrating behavioral health services in their ACOs. The ten-page brief examines models that integrate delivery of and payment for services, with a focus on five areas: financial incentives and sustainability, confidentiality of data sharing and provider supports for health information exchange, quality measurement, alignment with existing behavioral health initiatives, and potential regulatory and policy levers to overcome barriers to integration. The brief encourages states to capitalize on existing building blocks for integration, including health homes and federal Healthcare Innovation Awards, and to move from ACOs to TACOs (totally accountable care organizations) by expanding their scope of accountability to include broader social services, such as housing. To achieve this broader goal, the authors note, it is important to identify approaches that support the participation—and accountability—of behavioral health providers. Considerations for Integrating Behavioral Health Services Within Medicaid Accountable Care is available on the CHCS Web site (www.chcs.org).

AHRQ updates review of behavioral interventions for children with ASD: Families of children with autism spectrum disorder (ASD) pursue a range of treatments to address their children’s substantial impairments in social communication and interaction, including behavioral, educational, medical, allied health, and complementary approaches. The Agency for Healthcare Research and Quality (AHRQ) has released a review of current research on behavioral interventions for children with ASD. The review updates the previous AHRQ review, which was published in 2011. The authors summarize findings from 65 unique studies (48 randomized trials and 17 nonrandomized comparative studies). They rate the quality of the evidence from good (19 studies), to fair (39 studies), to poor (seven studies) and note that study quality has improved since the 2011 review. However, the strength of evidence and confidence in the stability of the effects of the intervention in the face of future research were rated low for many interventions. Early intervention based on high-intensity applied behavior analysis over extended time frames was associated with improvement in cognitive functioning and language skills. Early intensive parent training programs were effective in modifying parenting behaviors; however, data were more limited about the ability of these approaches to improve developmental skills beyond language gains for some children. Studies examining the effects of cognitive-behavioral therapy on anxiety reported positive results among older children with IQs of 70 or higher. The authors conclude that a growing evidence base suggests that behavioral interventions can be associated with positive outcomes, but studies with more methodological rigor across additional settings are needed. The 138-page review, Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update, is available on the AHRQ Web site (effectivehealthcare.ahrq.gov).

Two CSG Justice Center reports focus on juvenile justice outcomes: Two publications released by the Council of State Governments (CSG) Justice Center offer state and local governments recommendations to improve outcomes for youths who come into contact with the juvenile justice system. The first, Measuring and Using Juvenile Recidivism Data to Inform Policy, Practice, and Resource Allocation, summarizes findings from a fall 2013 survey of all 50 states’ juvenile correctional agencies. The survey found that agencies in 11 states (22%) do not track recidivism rates. Of the 39 states that do, 18 (46%) gather data on only a single type of contact with the justice system, stopping short of determining, for example, whether a youth was later incarcerated in the adult system. Based on these and other findings, the 16-page report focuses on five recommendations: measure recidivism by considering the multiple ways that youths may have subsequent contact with the justice system; analyze recidivism data to account for youths’ risk levels and other key characteristics; develop and maintain the infrastructure necessary to collect, analyze, and report recidivism data; make recidivism data available to key constituents and the general public; and use recidivism data to inform juvenile justice policy, practice, and resource allocation. The second report, Core Principles for Reducing Recidivism and Improving Other Outcomes for Youth in the Juvenile Justice System, was written as a guide for government leaders, juvenile justice system personnel, researchers, and advocates. It focuses on how to better leverage existing research and resources to facilitate system improvements that reduce recidivism and improve other outcomes. Part 1 distills research from which the eight core principles are derived, and part 2 details lessons learned on how to implement the principles effectively, with examples from specific programs. The reports are available on the CSG Justice Center Web site (csgjusticecenter.org).

NASHP roadmap to improve policy makers’ decisions: In a rapidly changing health care environment, making informed decisions to improve access and quality is difficult. To help inform such decisions, the federal government and other organizations have increased funding for two specific avenues of research: comparative effectiveness research (CER) and patient-centered outcomes research (PCOR). However, such studies are valuable only to the extent that findings are used by policy makers. The National Academy for State Health Policy (NASHP) has published a roadmap to guide policy makers in the use of CER and PCOR, especially those who are new to such research. Information for the roadmap was obtained from several sources, including a national survey of 494 state health policy makers and interviews with Medicaid and other public health officials, workers’ compensation directors, state employee health benefits directors, and others. Guidance is provided for six specific steps. Steps 1 through 3 provide information to identify when CER and PCOR can be useful and strategies to find and evaluate the available research. Steps 4 and 5 review approaches for using the evidence-based findings in designing a program or policy and communicating the findings after a decision is made. Step 6 addresses the need to evaluate the program or policy and monitor new CER and PCOR as it becomes available. A final section offers “stories from the road,” providing case studies of states’ use of CER in the decision-making process. The 49-page document, A Roadmap for State Policymakers to Use Comparative Effectiveness and Patient-Centered Outcomes Research to Inform Decision Making, is available on the NASHP site (wwwnashp.org).

Brookings Institution’s illustrated primer on new health care payment models: Payment reform in health care is confusing, but the goal is simple: How can health care providers change their economic incentives to encourage value over volume? A new resource from the Brookings Institution provides a basic overview of common approaches to payment reform in today's health care marketplace. The Beginner's Guide to New Health Care Payment Models explains the fee-for-service system, accountable care organizations, bundled and unbundled payment models, patient-centered medical homes, and pathways models to create savings. Each of these models is illustrated by a helpful graphic that users can download and use in their own presentations. The Web site also features a short video in which Patrick Conway, M.D., head of the Center for Medicare and Medicaid Innovation, discusses how the new payment models are being used to support innovations in oncology. These resources are available on the Brookings Institution’s Web site (www.brookings.edu).

KCMU issue brief profiles newer Medicaid health homes: In August 2012, the Kaiser Commission on Medicaid and the Uninsured (KCMU) published a report on the first Medicaid health home programs to be approved in six states: Missouri, Rhode Island, New York, Oregon, Iowa, and North Carolina. A new KCMU brief describes health home programs in nine states that have taken up the option in the intervening two years: Alabama, Idaho, Maine, Maryland, Ohio, South Dakota, Washington, Wisconsin, and Vermont. The Affordable Care Act (ACA) provided state Medicaid programs the option of implementing health homes for individuals with chronic conditions, giving states a new tool to improve care coordination and reduce costs for high-need populations. The ACA also provided a 90% federal match rate for health home services during the first two years. States implement programs in their own ways, reflecting different targeting priorities, underlying delivery and payment systems, and visions of delivery system reform, as well as other state-level factors. The KCMU issue brief details how the nine states differ in key areas: geographic scope, target population, service providers in the health home programs, fee-for-service versus managed care arrangements, and health home providers’ use of health information technology. The 19-page brief, Medicaid Health Homes: A Profile of Newer Programs, is available on the KCMU Web site (kff.org/medicaid).