Behavioral Health

NEWS BRIEF

(http://www.dshs.state.tx.us/sa/bhnb.shtm)

Informing policy and practice in mental health and substance abuse services through data

Volume 3 n Issue 4 n August 1, 2008

HOSPITAL DATA HIGHLIGHTS

Special Needs Program Reduces Use of Restraint among Clients Dually Diagnosed with Mental Illness and Mental Retardation

Recently, Big Spring State Hospital (BSSH) has been seeking ways to reduce the use of restraint among clients dually diagnosed with mental illness and profound to moderate mental retardation.

From this effort, came the BSSH Special Needs Program. Beginning in SFY2007, a full-time coordinator develops an individualized restraint prevention plan for each person referred. A detailed evaluation is conducted using the client’s history, reason for admission, current observations, and information from the family and previous caregivers to identify successful and unsuccessful treatment approaches. The special needs coordinator then presents a specific restraint prevention plan to BSSH unit staff in training meetings, which in turn, is cascaded down to shift-to-shift staff. Individual restraint prevention plans include modifications to the setting, rehabilitative interventions tailored to the client’s schedule, and any other techniques to meet the special needs of the client.

But is the BSSH Special Needs Program working? To answer this question, Bill Manlove (Hospital Management Data Services Unit, DSHS) examined the number of restraint episodes and restraints per client at BSSH pre (SFY2006) vs. post (SFY2007) implementation of the Special Needs Program for individuals diagnosed with both mental illness and mental retardation.

Figure 1 shows a 72% reduction in the number of restraint episodes at BSSH from pre-implementation in SFY2006 (407) to post-implementation in SFY2007 (114).

Moreover, there was a 55% drop in the number of restraints per client at BSSH from pre-implementation in SFY2006 (11) to post-implementation in SFY2007 (5).

The Special Needs Program at BSSH seems to be working to dramatically reduce the use of restraint among individuals dually diagnosed with mental illness and mental retardation.


COMMUNITY MENTAL HEALTH DATA HIGHLIGHTS

Consumer Satisfaction Surveys Help to Evaluate Performance of Mental Health System

The annual Adult Mental Health Survey (AMHS) and Youth Services Survey for Families (YSSF), as designed by the federal Mental Health Statistics Improvement Program, are administered annually (via mail) by Judy Temple and Flora Batts (Strategic Decision Support, Texas Health and Human Services Commission). Both surveys measure consumer perception of state community mental health services as part of a broader federal effort to evaluate the performance of the mental health system. The AMHS and YSSF assess general consumer satisfaction with state consumer mental health services, along with consumer perception of access to services, participation in treatment, outcomes achieved, improved functioning, and social connectedness. However, whereas the AMHS also measures consumer satisfaction with service quality, the YSSF includes a staff cultural sensitivity domain. Although the return rate is relatively low (e.g., SFY2007 AMHS = 19% and YSSF = 18%), sufficient numbers of surveys were completed to suggest that the results represent the overall populations being surveyed. Survey results are taken into account by DSHS and DSHS-Funded Community Mental Health Centers staff in an effort to improve the community mental health system in Texas. Table 1 (AMHS) and Table 2 (YSSF) display survey results for SFY2004 to SFY2007.

Table 1. Percent of consumers served at DSHS-Funded Community Mental Health Centers who agreed or strongly agreed with the items in the domains on the Texas Adult Mental Health Survey (AMHS) in State Fiscal Year (SFY) 2004-07.

State
Fiscal Year
(SFY) / General
Satisfaction / Perception of …
Service
Quality / Access
to Services / Participation
in Treatment / Outcomes
Achieved / Improved Functioning* / Social
Connectedness*
2004 / 84% / 80% / 76% / 63% / 60%
2005 / 87% / 83% / 79% / 72% / 60%
2006 / 85% / 84% / 76% / 72% / 53%
2007 / 86% / 81% / 73% / 66% / 56% / 58% / 63%

* Domains piloted in SFY2006. Source: Strategic Decision Support, HHSC.

Table 2. Percent of consumers (parents) served at DSHS-Funded Community Mental Health Centers who agreed or strongly agreed with the items in the domains on the Youth Services Survey for Families (YSSF) in State Fiscal Year (SFY) 2004-07.

State
Fiscal Year
(SFY) / General
Satisfaction / Perception of …
Staff Cultural Sensitivity / Access
to Services / Participation
in Treatment / Outcomes
Achieved / Improved Functioning* / Social
Connectedness*
2004 / 83% / 94% / 81% / 88% / 65%
2005 / 77% / 90% / 78% / 85% / 52%
2006 / 81% / 90% / 80% / 87% / 59%
2007 / 80% / 91% / 80% / 86% / 57% / 57% / 77%

* Domains piloted in SFY2006. Source: Strategic Decision Support, HHSC.

Clearly, the results over time for both the AMHS and YSSF suggest that after several years of fluctuation (possibly related to changes in survey methods), as of SFY2007, survey results seem to be stabilizing and indicate a relatively high degree of consumer satisfaction. (Although AMHS survey results showed that participation in treatment decreased from 72% in SFY2006 to 66% in SFY2007, this was not a statistically significant change.) More information about the consumer satisfaction surveys for DSHS-funded community mental health may be found on the DSHS website (http://www.dshs.state.tx.us/mhreports/Surveys.shtm).


SUBSTANCE ABUSE DATA HIGHLIGHTS

Youth Substance Abuse Indicated Prevention and Treatment Making a Difference

Substance abuse among youth in Texas is of serious concern to DSHS. After all, research has shown that substance use among adolescents (10-18 years of age) can lead to violent and aggressive behavior, motor vehicle fatalities, juvenile/criminal justice involvement, unintended sexual activity, and infectious disease. As part of its continuum of care, DSHS funds substance abuse prevention programs that are indicated for youth who are experimenting with alcohol or drugs and are most at risk for becoming dependent (e.g., school failure, interpersonal social problems, antisocial behavior, depression, etc.), along with treatment programs for those already abusing substances. But do these DSHS-funded substance abuse indicated prevention and treatment programs make a positive difference in the lives of Texas youth? To answer this question, Martin Arocena, Ph.D., (Decision Support Unit, Mental Health & Substance Abuse Services) examined youth who received DSHS-funded evidence-based youth substance abuse indicated prevention, and those who received substance abuse treatment.

Youth Substance Abuse Indicated Prevention

In SFY2007, DSHS funded 52 community-based organizations to educate youth most at risk for substance abuse about the adverse health consequences of the consumption of alcohol and drugs, communication and refusal skills, and interpersonal strategies for those who may have felt socially isolated. Of the 27,553 youth served in SFY2007, 70% successfully completed their youth substance abuse indicated prevention program. Moreover, according to program records, providers of DSHS-funded substance abuse indicated prevention successfully referred 10,545 youth to DSHS-funded substance abuse treatment or other support services.

Youth Substance Abuse Treatment

DSHS is making a concerted effort to promote the use of evidence-based treatment strategies for substance abuse among its funded providers, including Motivational Enhancement Therapy (MET; a systematic intervention for evoking

rapid, client-motivated change), Cognitive Behavioral Therapy (CBT; a therapeutic approach that focuses on changing patterns of thinking that are maladaptive and the beliefs that underlie such thinking), and both MET and CBT for the treatment of marijuana among youth.

Among 7,042 youth admitted to DSHS-funded substance abuse treatment in SFY2007, most were male (76%), between 15 and 16 years of age (57%), of Hispanic origin (58%), and involved with the legal system (80%), with over 55% referred to treatment as part of probation or parole. The most frequently reported primary substance at admission was marijuana (75%), but alcohol (8%), cocaine (6%), crack (1%), and inhalants (1%) were also reported.

Most youth admitted to DSHS-funded substance abuse treatment receive outpatient services, although those whose substance abuse is more severe receive intensive or supportive residential services. As Table 3 shows, the percentage of youth successfully completing DSHS-funded substance abuse treatment varies according to service intensity, with the highest completion rates among youth admitted to supportive residential services during SFY2000, SFY2004, and SFY2007. However, completion rates have remained relatively high at each level of service intensity from SFY2000 to SFY2007, with the greatest gains involving outpatient services. Whereas only 48% completed outpatient services in SFY2000, 56% of youth successfully completed DSHS-funded substance abuse outpatient services in SFY2007.

Table 3. Percentage of youth successfully completing DSHS-Funded Substance Abuse Treatment

by service intensity in State Fiscal Years (SFYs) 2000, 2004, and 2007.

Service Intensity / State Fiscal Year (SFY)
SFY2000
(N = 4,272) / SFY2004
(N = 6,266) / SFY2007
(N = 7,042)
Outpatient Services / 48% / 54% / 56%
Intensive Residential Services / 67% / 65% / 63%
Supported Residential Services* / 88% / 88%

*Service intensity not available for comparison in SFY2000.

Source: DSHS Behavioral Health Integrated Provider System (BHIPS).

Both youth substance abuse indicated prevention and treatment are indeed making a positive difference in the lives of Texas youth.

WHAT THE RESEARCH LITERATURE TEACHES US

Effects of Enhanced Foster Care on the Long-Term Physical and Mental Health of Foster Care Alumni

Research has shown that children who are mistreated are at a higher risk for developing mental disorders and physical illnesses as adults. Although the child welfare system routinely places severely abused and/or neglected children in foster care, few controlled studies have been conducted to determine the effectiveness of foster care in improving the long-term health of mistreated youth. In the first study of its kind, Ronald Kessler, Ph.D., from Harvard Medical School, and his colleagues, evaluated the effects of foster care treatment on the mental and physical health of adult foster care alumni. Participants were 479 adult foster care alumni who were placed in foster care as adolescents (14 to 18 years of age) between January 1, 1989 and September 30, 1998, in private (n=111) or public (n=368) foster care programs in Oregon and Washington state. (The latter alumni were eligible for, but not selected by, the private foster care program because of limited openings.) Personal interviews administered 1 to 13 years after leaving foster care assessed the mental and physical health of alumni. More than 80% of alumni were traced, and 92% of those traced were interviewed. The results, published in the June 2008 issue of Archives of General Psychiatry, indicate that private foster care program alumni had significantly fewer mental disorders (i.e., major depression, anxiety disorders, and substance use disorders), ulcers, and cardio-metabolic disorders, but more respiratory disorders, than did public foster care program alumni. Importantly, caseworkers in the private foster care program had higher levels of education and salaries, lower caseloads, and access to a wider range of ancillary services (e.g., mental health counseling, tutoring, and summer camps) than caseworkers in the public foster care programs. Also, youth in the private programs were in foster care more than two years longer than those in the public foster care programs. Clearly, these findings suggest that public sector investment in higher-quality foster care services in Texas could substantially improve the long-term mental and physical health of foster care alumni.

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Kessler, R.C., Pecora, P.J., Williams, J., Hiripi, E., O’Brien, K., English, D., White, J., Zerbe, R., Downs, A.C., Plotnick, R., Hwang, I., & Sampson, N.A. (2008). Archives of General Psychiatry, 65(6), 625-633.


Nurse Practitioner and Physician Assistant Interest in Prescribing Buprenorphine

Office-based buprenorphine (i.e., a prescription medication for people addicted to heroin or other opiates that acts by relieving the symptoms of opiate withdrawal such as agitation, nausea and insomnia) places health care providers in a unique position to combine HIV and drug treatment in primary care settings. However, federal legislation restricts nurse practitioners and physician assistants from prescribing buprenorphine, which may limit its potential for uptake and inhibit the role of these nonphysician providers in delivering drug addiction treatment to patients with HIV. In a study published in the June 2008 issue of the Journal of Substance Abuse Treatment by Robert Roose, M.D., M.P.H.a, , , at Montefiore Medical Center/Albert Einstein College of Medicine, and his associates, examined the level of interest in prescribing buprenorphine among nonphysician providers. The researchers anonymously surveyed nonphysician providers (n = 189), as well as generalist physicians (n = 177), and infectious disease specialists (n = 125) attending HIV educational conferences in six large U.S. cities about their interest in prescribing buprenorphine between February and May 2006. (The conferences took place in New York, Chicago, Atlanta, Los Angeles, San Francisco, and Washington, DC.) Overall, 48.6% of nonphysician providers were interested in prescribing buprenorphine. Moreover, compared to infectious disease specialists, nonphysician providers and generalist physicians were significantly more likely to be interested in prescribing buprenorphine. Indeed, the findings suggest that nurse practitioners and physician assistants are interested in prescribing buprenorphine. Therefore, to improve uptake of buprenorphine in primary care settings in Texas and other states, the implications of permitting nonphysician providers to prescribe buprenorphine should be further explored.

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Roose, R.J., Kunins, H.V., Sohler, N.L., Elam, R.T., & Cunningham, C.O. (2008). Journal of Substance Abuse Treatment, 34(4), 456-459.