Community Health Workers (CHW) are individuals with an understanding of the communities they serve, employed within healthcare and human service systems to assess health and social needs of community members and connect individuals to needed services. In this study, CHWs employed by a behavioral health managed care organization (BHMCO) were trained in a care coordination intervention to address reasons for substance use disorder (SUD) admission, health-related determinants, and motivation for ongoing treatment, with the goal to improve care and reduce readmissions. This observational cohort study included 865 Medicaid-enrolled adults with SUD hospitalization or residential service in 2021–2024; 593 individuals (68.6

Certified Peer Specialists provide optional peer support services (PSS) to individuals with mental health disorders. In this effectiveness study, we describe changes in behavioral health service utilization in Medicaid-enrolled adults receiving PSS compared to propensity-score matched controls. Individuals receiving PSS (n = 2,156) in 2021–2024 were successfully matched 1:2 to individuals receiving outpatient mental health services without PSS (comparison; n = 4,312). Service rates were compared between groups over time (90 days before, during, and 90 days following the PSS or outpatient episode of care. Rates of services were higher for PSS; utilization for the majority of services declined over time. PSS versus the Comparison was associated with a steeper decline in psychiatric hospitalization, β = -.0190, t(2,932) = -2.61, p = .0090, and crisis service, β = -.0269, t(2,932) = -3.49, p = .0005 following discharge from the episode of care. PSS may successfully maintain recovery-oriented care through diversion from psychiatric hospitalization and increase community tenure resulting in a utilization pattern that is not observed with outpatient mental health service alone.

A behavioral health managed care organization in Pennsylvania expanded a bridging strategy associated with reducing multiple readmissions to Medicaid-enrolled adults with a first admission to an inpatient mental health service. The intervention consisted of active problem solving, screenings, assessment of individuals' motivation for ongoing treatment, care management services, and resource coordination. The intervention was associated with significantly lower rates of readmission and higher rates of aftercare receipt within 30 days compared with nonreceipt of the intervention. Direct cost savings were achieved through fewer readmissions, but longer-term savings may be achieved by affecting the illness trajectory for individuals with behavioral health disorders.

To address high-cost inpatient utilization for those with severe and persistent mental illness, stakeholders from a County Department of Human Services, a Behavioral Health Managed Care Organization, and mental health providers created a value-based payment (VBP) model to shift funding from inpatient mental health treatment (IPMH) to intensive, evidence-based, community-based mental health treatment, Assertive Community Treatment (ACT). Using a retrospective observational study, individuals who received ACT from providers participating in the VBP (N = 2) were compared to individuals who received ACT from providers (N = 17) not supported through a VBP. Results show decreasing average ACT and IPMH expenditures as well as shorter lengths of stay over time for providers under a VBP compared to those not in a VBP. Access to care was not impacted. These results, including implications for behavioral health, are discussed in the context of quality of care.

Family Based Mental Health Services (FBMHS) with an embedded clinical model, Ecosystemic Structural Family Therapy, is an intervention designed for youth with a serious emotional disturbance (SED) who are at risk of out-of-home placement. The current evaluation examines the association between receipt of FBMHS and rates of out-of-home and community-based care during and after an episode of FBMHS. We identified 25,016 Medicaid-enrolled youth ages 3 to 17 years with receipt of a new FBMHS episode from 1/1/2015 to 6/30/2021. 14

BACKGROUND:The negative impact of trauma on health is devastating. Providers, especially those in rural areas, require support to implement trauma-informed care (TIC) on a systems level.OBJECTIVES:This paper describes a partnership of county behavioral health administrators, service providers, and a behavioral health managed care organization and steps taken over a 5-year initiative to enhance capacity and quality of community services to meet the needs of individuals in a rural setting to receive TIC.METHODS:The initiative included trainings in evidence-based and best practices in TIC, improved trauma screening, development of TIC centers, and development of community-based networks for ongoing support. Lessons learned were summarized through discussions between partnership members.LESSONS LEARNED:Shared ownership, opportunity to build networks, and continuous assessment of organizational strengths resulted in successful implementation and sustained practice. Challenges included turnover among staff and organizations.CONCLUSIONS:Building a TIC network across a rural health care system can be successful with long-term support and investment from multiple stakeholders.

Introduction Peer support service in substance use disorder systems (PS SUD) is an optional supplement to treatment services for Medicaid-enrolled individuals across Pennsylvania. The value of PS SUD was defined through association with improved service utilization patterns. We examined service utilization in a subset of individuals receiving PS SUD following an acute service (hospitalization or withdrawal management) compared to utilization in propensity-score-matched controls via an observational analysis. Methods We identified all Medicaid-enrolled adults with receipt of PS SUD from 2016 to 2019 and included those with prior acute service (n = 349); the study successfully matched all to individuals receiving outpatient SUD services without peer support (n = 698). Individuals were matched on age, gender, race, ethnicity, diagnosis, and prior utilization of acute care. A large percentage of individuals receiving PS SUD (74 %) had co-occurring mental health diagnoses, which we included in matching. We examined service utilization rates via administrative paid claims data for both groups in the first 90 days following peer support/outpatient discharge. Results Acute service utilization differed between groups over time, p = .0014. We observed a larger reduction in the rate of acute care during PS SUD service (8.6 %) versus outpatient service (21.2 %), with lower rates remaining 90 days following PS SUD (13.8 %) or outpatient discharge (16.8 %). Individuals receiving PS SUD showed connection to community-based services in the 90 days following discharge from PS SUD, including 45.0 % receiving outpatient SUD and 31.8 % receiving outpatient mental health services. Conclusions Peer support may help individuals to navigate the behavioral health system and reduce hospitalization or other restrictive levels of care.

Purpose of Study: Gatekeeper training for individuals who may be in contact with someone contemplating suicide is a recommended suicide prevention strategy. This study assessed organizational-level gatekeeper training. Primary Care Setting(s): Gatekeeper training was conducted in a behavioral health managed care organization (BHMCO), which facilitates integrated behavioral and physical health services for 1.4 million Medicaid-enrolled Pennsylvanians. Methodology and Sample: Gatekeeper training was offered to BHMCO staff via a new training policy. Gatekeeper trainers were qualified BHMCO staff. Approximately half (47%) of trained staff served as care managers. Pre- and posttraining surveys were administered to assess self-reported confidence in ability to identify and assist individuals at risk for suicide. Post-training, staff responded to a hypothetical vignette involving suicide risk, which was evaluated for skills by gatekeeper trainers. Results: Eighty-two percent of staff completed training. Mean confidence scores improved significantly from pre- (η = 615) to posttraining (η = 556) (understanding = 3.41 vs. 4.11, respectively; knowledge = 3.47 vs. 4.04; identification = 3.30 vs. 3.94; respond = 3.30 vs. 4.04, p < .0001 for each). Intermediate and advanced skills to address suicide risk were demonstrated post-training in 68.6% and 17.2% of staff, respectively. More care managers versus other BHMCO staff demonstrated advanced skills (21.6% vs. 13.0%); however, both groups showed significant improvement pre- to post-training. Implications for Case Management: Care managers benefit from suicide prevention training and are uniquely positioned to serve as organizational leaders to successful population health initiatives to decrease suicide through training and education.

This study investigated the sustainability of a multi-agency 15-month Learning Collaborative (LC) for implementing trauma-informed care in 23 rural Pennsylvania counties. Provider agencies (N = 22) were assessed three years following completion of the LC. Sustained trauma-informed practices were assessed through criteria indicating organizational achievement as a trauma-informed care center. A theoretical model of clinical training was applied to determine the extent to which training- and skill-related factors were associated with sustained trauma-informed care. Three years after the LC, trauma symptom screening rates and staff training improvements were sustained, while staff confidence in delivering trauma-informed care worsened across time. Sustained trauma-informed care was associated with implementation milestone completion and third-party ratings of quality improvement skills during the LC. Building capacity for organizational change through training and skill development during active phases of implementation is important for sustained trauma informed care in behavioral health service.

Behavioral Health Rehabilitation Service (BHRS) is a comprehensive service for Pennsylvania's Medicaid-enrolled youth and their families. In 2021, BHRS transitioned to Intensive Behavioral Health Service (IBHS) through state-wide policy change. To assess impact, the largest behavioral health managed care organization in the state compared service utilization in BHRS in 2019 versus IBHS in 2021. Results show that significantly more youth received non-Applied Behavior Analysis (non-ABA) services in BHRS (n = 13,795) than IBHS (n = 10,083) and more youth were discharged during the measurement period for BHRS versus IBHS (47% vs. 44%). Significantly more youth received ABA through IBHS versus BHRS (n = 4,385 vs. n = 2,690). The number of youth served in therapeutic service in IBHS did not indicate improved access during this first year of transition; however, more youth received evidence based treatments through IBHS indicating higher quality care for some youth and families.

Trauma exposure can negatively impact health. Trauma-informed care implementation within health care systems may improve the identification and treatment of trauma-related illness on a population health level. The current study investigated outcomes of a multiagency implementation of trauma-informed care for Medicaid-enrolled adults and children in 23 rural Pennsylvania (United States) counties. Changes in trauma symptom screening, the number of staff trained in trauma-informed care, and clinician confidence in using trauma-informed care were assessed in participating treatment agencies (N = 22) over the course of a 15-month trauma-informed care learning collaborative (TLC). Data included monthly agency-reported screening, training, and confidence outcomes, which were analyzed using repeated-measures analyses of variance. Trauma symptom screening rates improved from 41.1% (SD = 43.0%) to 93.3% (SD = 12.0), p < .001; ηp 2 = .30. The average number of cumulative staff members trained in trauma-informed care per agency increased from 24.43 (SD = 42.22) to 140.00 (SD = 150.87), p < .001, Kendall's W = .09. The percentage of agencies that reported high confidence in delivering trauma-informed care increased from 15.8% (SD = 15.5%) to 80.5% (SD = 17.7%), p < .001; ηp 2 = .45. Pairwise comparisons revealed both screening rates and confidence ratings reached significant improvement in Month 11 of the TLC, suggesting that these processes may be related. A total of 2,935 staff members were trained during the TLC. The immediate impact of system-level implementation of trauma-informed care was evident for agency processes and staff confidence, with support provided by multiple stakeholders.

PURPOSE OF STUDY:To examine the effectiveness of a care management intervention to decrease readmissions and to better understand clinical and social determinants associated with readmission.PRIMARY PRACTICE SETTING:Inpatient mental health (MH) and substance use disorder (SUD) facilities, nonhospital SUD withdrawal management and rehabilitation facilities.METHODOLOGY AND SAMPLE:The authors identified 3,950 Medicaid-enrolled individuals who received the intervention from licensed clinical staff of a behavioral health managed care organization; 2,182 individuals were eligible but did not receive the intervention, for treatment as usual (TAU). We used logistic regression to examine factors associated with readmission. Determinants of readmission were summarized through descriptive tests.RESULTS:The intervention was associated with lower readmissions to SUD facilities compared with TAU (6.0% vs. 8.6%, p = .0002) and better follow-up to aftercare. Controlling for clinical differences between groups, regression results found increased odds of readmission for male gender (odds ratio [OR]: 1.33; 95% confidence interval [CI]: 1.16-1.52, p < .0001) and dual MH and SUD diagnoses (OR: 1.52; CI: 1.29-1.79, p < .0001). Prior inpatient and case management services were also associated with increased odds for readmission. In the regression model, the intervention was not associated with decreased odds for readmission. Individuals with readmission (n = 796) were more likely to report being prescribed psychotropic medication and having housing difficulties and less likely to report having a recovery plan than those without readmission.IMPLICATIONS FOR CASE MANAGEMENT PRACTICE:Characteristics of Medicaid populations with hospitalization may contribute to readmission, which may be mitigated through care management intervention.

Background: High staff turnover rates are a burden for behavioral health providers because they may negatively impact staff morale, quality of care, and clinical outcomes as well as increase costs. The Staff Assessment and Retention (STAR) Project is a partnership between a behavioral health managed care organization and community-based providers designed to: 1) share information on research-based approaches, 2) identify strategies that providers find successful yet feasible, and 3) develop a learning community around research-based, community-informed strategies to increase staff retention. Methods: Participants from 87 community-based behavioral health providers completed a survey about successful strategies and barriers to staff retention, current retention and turnover rates, and ratings of commonly used strategies supported by research. Results were shared and discussed across the partnership through a learning community including a webinar co-facilitated by two participating providers. Results: Successfully demonstrated but less utilized strategies included use of exit and stay interviews, training in best practices, availability of electronic records and other technology, and flexible work schedules. Providers reported the type of employment offered (full or part time, benefits, competitive wage; reported in 17% of responses), ability to offer trainings and staff development (13%) and using staff feedback (10%) were most important to retention. Conclusions: The partnership demonstrated that providers desire a vehicle for sharing ideas and problem-solving issues related to the behavioral health workforce. The endorsement by several community-based providers of lower-utilized strategies known to improve retention would not be realized across the community without the collaboration of the payer-provider partnership.

Research ObjectiveBehavioral Health Home Plus (BHHP) is an evidence‐based model to enhance physical health and wellness for individuals with serious mental illness (SMI) and chronic medical conditions. To better understand model effectiveness and best practices for dissemination, we implemented BHHP in 7 adult Opioid Treatment Programs (OTP) and 5 youth Residential Treatment Facilities (RTF).Study DesignWe utilized a hybrid study design to examine dissemination and support of BHHP through a 12‐month Learning Collaborative (LC) and outcomes via propensity‐score matched analyses. Mixed methods included semi‐structured staff interviews and confidence surveys to assess feasibility. Data were collected on involvement/confidence in managing physical health (survey) and utilization of primary/specialty care and unplanned healthcare (claims) over 18‐months.Population StudiedIn Pennsylvania's Medicaid HealthChoices program, behavioral health agencies serve as health homes with support and training in wellness by a behavioral health managed care organization, Community Care Behavioral Health of the UPMC Insurance Services Division. Enrollment into BHHP for OTP included adults (n = 689), average age 39.19 ± 9.99 years, 60% female and youth (n = 354) for RTF, average age 14.04 ± 2.52 years, 31% female. Propensity score matching was successful for OTP (n = 688) and RTF (n = 312) members.Principal FindingsProviders reported barriers (training time, staff turnover, workflow integration, family engagement) and facilitators (model resources, education on population‐specific health topics, learning from other sites implementation experiences) to implementation. At 18‐month follow up, over 70% of staff reported being highly confident in working with individuals on physical health and wellness; over 60% of service‐users reported being highly involved in working with their behavioral health provider on physical health and wellness, and 67% of OTP and 43% of RTF service‐users reported being highly confident in their ability to manage their physical health and wellness.Service utilization outcomes showed large decreases over 18 months in medically emergent care for OTP members while rates remained steady for the matched comparison group (p = 0.0055); a similar pattern was found for medications for physical health chronic conditions (p < 0.0001). For OTP, more individuals remained connected to ambulatory substance use disorder services in the comparison group at 18 months. For RTF both intervention and comparison groups showed decreased behavioral health hospitalizations; however, a greater proportion of the intervention group remained connected to ambulatory psychiatric service at 18 months (62% v. 48%). The comparison group showed larger decreases in medically emergent care over time (p = 0.0186).ConclusionsSites have fully integrated the BHHP model into workflows and promote physical health and wellness amongst their complex and medically vulnerable populations. BHHP is associated with positive changes in service utilization outcomes but was comparable to matched comparison groups.Implications for Policy or PracticeHealth homes offer an opportunity for improved health outcomes for vulnerable populations with chronic conditions. The LC approach, which allows for full virtual implementation, is an effective and scalable approach to wide‐spread implementation and successful uptake of care models.Primary Funding SourcePatient‐Centered Outcomes Research Institute.

OBJECTIVESTo compare patterns of psychiatric hospitalization and readmission within 30 days for Medicaid expansion (expansion) vs previously insured (legacy) samples.STUDY DESIGNRetrospective analysis using Medicaid behavioral health service claims.METHODSWe identified 24,044 individuals with hospitalizations in calendar years 2017 and 2018 within the network of a behavioral health managed care organization in Pennsylvania. Logistic regression was used to examine factors associated with readmission.RESULTSIndividuals covered under expansion (n = 7747) vs legacy (n = 16,297) were older and more likely to be male and European American, with higher rates of cooccurring mental health (MH) and substance use disorder (SUD) diagnoses, as well as lower rates of MH and SUD services in the 30 days prior and any prior MH hospitalization. A higher proportion of individuals with expansion vs legacy status were readmitted (11.3% vs 9.0%; P < .0001). Controlling for factors associated with readmission, regression showed an increased likelihood of readmission for expansion vs legacy status (adjusted odds ratio [AOR], 1.23; 95% CI, 1.12-1.35; P < .0001). Increased risk for readmission was also found across populations for male patients (AOR, 1.12; 95% CI, 1.02-1.22; P = .0124), those with prior MH hospitalizations (AOR, 1.65; 95% CI, 1.51-1.81; P < .0001) or other behavioral health services (AOR, 1.14; 95% CI, 1.03-1.26; P = .0142), those with longer hospitalization episodes (AOR, 1.01; 95% CI, 1.00-1.01; P < .0001), and those with cooccurring SUD (AOR, 1.58; 95% CI, 1.44-1.74; P < .0001).CONCLUSIONSIndividuals with coverage through Medicaid expansion compared with legacy coverage have an increased risk of psychiatric readmission and may warrant targeted interventions that also address service utilization and cooccurring SUD.

Research ObjectivePennsylvania has announced an initiative to prioritize state‐level action to become trauma informed, affecting culture, policy, and practice. The present study investigates support for the implementation and sustainability of trauma‐informed organizational, clinical, and milieu practices among rural behavioral health care providers.Study DesignA trauma‐informed care learning collaborative (TLC) following the Institute for Healthcare Improvement's Breakthrough Series Model was developed and implemented by a behavioral health managed care organization as part of a larger initiation to change organizational culture to become trauma informed. Innovative strategies to support trauma‐informed practice adoption and sustainability include an organizational self‐assessment and rubric guiding designation of organizations as Trauma Informed Care Centers. Aims of this initiative include monitoring consumer screening rates for exposure to trauma and increase staff confidence over the 15‐month TLC, provide training in evidence based practices, and implement the organizational Trauma Informed Care Center designation strategy.Population StudiedTwenty‐two mental health and/or substance use disorder provider organizations of outpatient, ambulatory care in rural Pennsylvania to Medicaid‐enrolled adults and children; initiative participation requires the involvement of organizational leadership, clinical staff, non‐clinical staff, and consumers and family members.Principal FindingsBy the fifth quarter of the initiative, over two thirds (68%) of participating organizations self‐assessed as either showing sustainable improvement or demonstrating outstanding sustainable results. Consumer trauma screening rates improved markedly over time, from 39.2% in the first quarter to 76.5% of consumers screened by the fifth quarter. Over half of agencies (55%) report screening rates better than 90%. Staff training scaled up rapidly, with over 2900 staff educated in trauma informed care in the first 15 months of the initiative (e.g. Trauma Focused Cognitive Behavior Therapy, Cognitive Processing Therapy, Trauma 101, Seeking Safety). Supervisors monitored 3–77 staff members each month depending on provider organization; the percentage of staff reporting high confidence in delivering trauma informed care rose from 18.6% in the first quarter to 68.0% in the fifth. After 3 years, there are currently 17 provider organizations designated as trauma informed Care Centers, of which all 17 meet exemplary center standards.ConclusionsThe trauma informed initiative has yielded positive changes in both process and outcomes with sustained improvement indicating trauma informed culture change on a systems level. This initiative has improved quality of care and access to trauma informed care for consumers.Implications for Policy or PracticeA learning collaborative framework can support the practitioner‐level and organizational‐level changes necessary to disseminate and implement a set of aligned clinical and organizational practices such as trauma‐informed practices. A specialty center designation rubric can further bolster this adoption process by providing organizations with additional incentive and with a structure to advance practice implementation and sustainability.

Community and School-Based Behavioral Health Service (CSBBH) was developed through a collaborative process that included schools, behavioral health providers, counties, and a payor. The clinical model within CSBBH relies on a common factors approach. To evaluate the effectiveness of CSBBH to meet the needs of students across a diverse state, clinical model performance and outcomes were examined for 2,584 Medicaid-eligible children aged 4.5 to 11 years in urban and rural communities. First, propensity score matching was used to compare CSBBH to Treatment as Usual (TAU). CSBBH was associated with greater improvement in child functioning and slightly lower therapeutic alliance compared to TAU. Next, the utility of the model for urban vs. rural students was compared. As expected, there were many differences at baseline between children in urban and rural settings. Compared to children from rural settings, children from urban settings were more culturally diverse and had higher rates of utilization of prior mental health services but had lower rates of complex diagnoses. Despite these differences, the service was consistently applied across schools and caregiver-reported outcomes were comparable and positive across groups. Teachers in urban and rural schools reported improvements in hyperactivity, but other outcomes (e.g., prosocial behavior, emotional symptoms) varied. This study highlights the importance of a scalable and sustainable payor–provider collaborative approach to address the needs of children across a diverse state.

Using measurement-based and feedback-informed approaches is key to providing effective family-centered clinical care; a strength-based approach is shown to improve treatment outcomes and satisfaction. Yet, there are few brief, psychometrically sound assessment tools for preschool-age and elementary school–age children. In response, we developed a nine-item, two-scale measure, the Weekly Assessment of Child Behavior–Positive (WACB-P), suitable for children ages 2 to 12 years. We examined the psychometric properties of the WACB-P based on two low-income clinical samples differing in intervention modality and location (Sample 1: N = 285; Sample 2: N = 137). WACB-P demonstrated high internal validity and test–retest reliability. The item response theory (IRT) paradigm applied to the Intensity Scale revealed that the items showed moderate discrimination and adequate precision, particularly effectively capturing behavioral challenges. Repeated-measures analysis of covariance (RM-ANCOVA) showed significant linear effects from session to session, suggesting sensitivity to change during treatment. WACB-P demonstrated strong convergent validity with established measures of child behavior problems. These favorable results position the WACB-P as a suitable choice for agencies providing measurement-based behavioral health care for young children and their families.

The present study is designed to evaluate the effectiveness of a health care integration model for adolescents to improve coordination and adolescent and family-reported outcomes. Adolescent Behavioral Health Home Plus (BHHP) is a comprehensive health care integration model that facilitates an interdisciplinary array of behavioral and medical care and social services for adolescents with chronic health conditions. Behavioral health nurses, case managers, and school-based (SB) staff are trained in wellness coaching with access to adolescent toolkits. A behavioral health-managed care organization (BHMCO) reports tier information used to help providers target appropriate services with highest need determined as having a serious emotional disturbance plus medical complexity or presence of pharmacy claims for 2 or more medications (eg, psychotropics and medications for diabetes, asthma, or hypertension). Adolescents with lower needs may provide opportunity for risk reduction.

This study examines the generalizability of a successful care management bridging strategy implemented by a behavioral health managed care organization to reduce readmission in psychiatric and substance use disorder (SUD) populations. The sample included 1724 individuals with a psychiatric or SUD hospitalization or detoxification service within 30-days of a prior SUD or inpatient event; 1243 Medicaid-enrolled adults received the intervention plus usual care, and 481 individuals received only usual care. Results included lower readmission to SUD facilities (p = .0012) and reduced odds of readmission among individuals with a SUD event (OR = 0.49, p = .0006) for the intervention versus the comparison group. Likelihood of readmission was higher for those with dual diagnoses (OR = 1.72, p = .0002) or in urban settings (OR = 1.47, p = .0010), with some evidence of the intervention’s success in these populations. Care management bridging strategies may be more effective for individuals who utilize SUD services and others who need help navigating complex systems of care.