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ObjectiveCrisis services are undergoing an unprecedented expansion in the United States, but research is lacking on crisis system design. This study describes how individuals flow through a well-established crisis system and examines factors associated with reutilization of such services.MethodsThis cross-sectional study used Medicaid claims to construct episodes describing the flow of individuals through mobile crisis, specialized crisis facility, emergency department, and inpatient services. Claims data were merged with electronic health record (EHR) data for the subset of individuals receiving care at a crisis response center. A generalized estimating equation was used to calculate adjusted odds ratios for demographic, clinical, and operational factors associated with reutilization of services within 30 days of an episode's end point.ResultsOf 41,026 episodes, most (57.4%) began with mobile crisis services or a specialized crisis facility rather than the emergency department. Of the subset (N=9,202 episodes) with merged EHR data, most episodes (63.3%) were not followed by reutilization. Factors associated with increased odds of 30-day reutilization included Black race, homelessness, stimulant use, psychosis, and episodes beginning with mobile crisis services or ending with inpatient care. Decreased odds were associated with depression, trauma, and involuntary legal status. Most (59.3%) episodes beginning with an involuntary legal status ended with a voluntary status.ConclusionsCrisis systems can serve a large proportion of individuals experiencing psychiatric emergencies and divert them from more restrictive and costly levels of care. Understanding demographic, clinical, and operational factors associated with 30-day reutilization may aid in the design and implementation of crisis systems.

ObjectiveThe authors investigated associations between rates of contact with individuals in distress during field visits by mobile crisis teams and client and referral source characteristics.MethodsIn this retrospective observational study of an urban mobile crisis program, call logs (N=2,581) were coded for whether an attempted field visit resulted in a client evaluation. Logistic regression analyses examined potential associations with client age, gender, race-ethnicity, primary language, living situation, insurance, and referral source.ResultsContact was made with 77% of adults and 97% of children referred to mobile crisis teams. Field visit contact rates differed by age. Unsuccessful visits were more likely when the referral source was from institutional settings than from individuals.ConclusionsApproximately one-quarter of attempted field visits with adults by an urban mobile crisis team were not completed, particularly among referrals from institutional settings. As mobile crisis services proliferate, field visit contact rate could be a key performance metric for these critical services.

OBJECTIVE: No widely accepted clinical guidelines, and scant directly applicable pragmatic research, are available to guide the prescription of psychiatric medications in low-threshold outpatient settings, such as street outreach, urgent care, and crisis care, as well as walk-in, shelter, and bridge and transition clinics. Providers frequently prescribe medications in these settings without patients having firm psychiatric diagnoses and without medical records to guide clinical decision making. Persons who receive medications in these settings often seek help voluntarily and intermittently for mental illness symptoms. However, because of structural and individual factors, such patients may not engage in longitudinal outpatient psychiatric care. The authors reviewed the literature on psychiatric medication prescribing in low-threshold settings and offer clinical considerations for such prescribing. METHODS: The authors conducted a rapid literature review (N=2,215 abstracts), which was augmented with up-to-date clinical prescribing literature, the authors collective clinical experience, and DSM-5 section II diagnostic criteria to provide considerations for prescribing medications in low-threshold settings. RESULTS: For individuals for whom diagnostic uncertainty is prominent, a symptom-based diagnostic and treatment approach may be best suited to weigh the risks and benefits of medication use in low-threshold settings. Practical considerations for treating patients with clinical presentations of psychosis and trauma, as well as mood, anxiety, and substance use disorders, in low-threshold settings are discussed. CONCLUSIONS: An urgent need exists to invest in pragmatic research and guideline development to delineate best-practice prescribing in low-threshold settings.

Mobile crisis services for people experiencing distress related to mental health or substance use are expanding rapidly across the US, yet there is little evidence to support these specific models of care. These new programs present a unique opportunity to expand the literature by utilizing implementation science methods to inform the future design of crisis systems. This mixed methods study will examine the effectiveness and acceptability of the Street Crisis Response Team (SCRT), a new 911-dispatched multidisciplinary mobile crisis intervention piloted in San Francisco, California. First, using quantitative data from electronic health records, we will conduct an interrupted time series analysis to quantitatively examine the impacts of the SCRT on people experiencing homelessness who utilized public behavioral health crisis services in San Francisco between November 2019 and August 2022, across four main outcomes within 30 days of the crisis episode: routine care utilization, crisis care reutilization, assessment for housing services, and jail entry. Second, to understand its impact on health equity, we will analyze racial and ethnic disparities in these outcomes prior to and after implementation of the SCRT. For the qualitative component, we will conduct semi-structured interviews with recipients of the SCRTs services to understand their experiences of the intervention and to identify how the SCRT influenced their health-related trajectories after the crisis encounter. Once complete, the quantitative and qualitative findings will be further analyzed in tandem to assist with more nuanced understanding of the effectiveness of the SCRT program. This evaluation of a novel mobile crisis response program will advance the field, while also providing a model for how real-world program implementation can be achieved in crisis service settings.

ObjectivesPeople with severe mental illness are 10 times more likely to have HIV/ AIDS than the general population, yet little is known about the characteristics and frequency of recognition of pre-existing HIV/AIDS diagnoses among inpatients with severe mental illness. This study examines documentation rates of pre-existing HIV/ AIDS among inpatients within psychiatric hospitals in New York State.DesignRetrospective cohort study to examine recognition of pre-existing HIV/AIDS among psychiatric inpatients.MethodsPatient-level Medicaid claims records were linked with hospital and regional data for people admitted to psychiatric inpatient units in New York State. Presence of HIV/AIDS diagnoses prior to psychiatric hospitalization was coded for each inpatient (n = 14 602). Adjusted odds ratios of undocumented HIV/AIDS diagnoses at the time of discharge were calculated using logistic regression analyses.ResultsAbout 5.1% (741/14 602) of unique psychiatric inpatients had pre-existing HIV/AIDS diagnoses. Of these inpatients, 58.3% (432/741) were not coded as having HIV/AIDS upon discharge. Higher rates of missed detection were associated with younger age, non-Hispanic white race/ethnicity, shorter length of stay, more distal coding of an HIV/AIDS diagnosis, and fewer HIV/AIDS-related Medicaid claims in the past year. Hospitals with higher readmission rates also had higher rates of undetected HIV/AIDS diagnoses.ConclusionOver half of inpatients previously diagnosed with HIV/AIDS did not have their HIV-positive status noted upon discharge from psychiatric hospitalization. This finding underscores how frequently clinically significant medical comorbidities fail to be incorporated into psychiatric treatment and treatment planning. Inpatient clinicians are missing important opportunities to optimize HIV/AIDS treatment and reduce morbidity and mortality.

Federal and institutional policy changes have accelerated the use of telemental health to care for college students distant from their mental health providers during the early part of the COVID-19 pandemic. Temporary measures have made telemental health more readily available, including relaxing of regulations related to interstate licensure, controlled substance prescribing, patient privacy, and reimbursement. Though early efforts are underway to sustain these changes during and in the wake of the pandemic, there are important areas in which federal and institutional policy are still lacking. Additional steps are needed to successfully implement and sustain telemental health for college students include ensuring student access to technology and Internet; proactive outreach to optimize the student's home environment, addressing concerns about safety and confidentiality; developing the means to track rapidly shifting telemental health policy changes; and developing centralized resources that enable remote providers to become familiar with involuntary commitment laws and emergency protocols.

Initiatives that support and incentivize the integration of behavioral health and general medical care have become a focus of government strategies to achieve the triple aim of improved health, better patient experience, and reduced costs. The authors describe the components of four large-scale national initiatives aimed at integrating care for a wide range of behavioral health needs. Commonalities across these national initiatives highlight health care and social services needs that must be addressed to improve care for people with co-occurring behavioral health and general medical conditions. These findings can inform how to design, test, select, and align the most promising strategies for integrated care in a variety of settings.

ObjectiveThis study examined the extent to which prehospital treatment engagement is related to posthospital follow-up treatment among psychiatric inpatients and whether the effects of inpatient discharge planning on posthospital follow-up treatment vary by level of pretreatment engagement in care.MethodsNew York State Medicaid and other administrative databases were used to examine service use by 18,793 adult patients discharged to the community after inpatient psychiatric care in 2012-2013. Outcomes included attending an outpatient mental health service within 7 days and within 30 days after discharge. The sample was stratified by whether patients had high, partial, low, or no engagement in outpatient psychiatric services in the 6 months before admission.ResultsScheduling an outpatient appointment as part of the patient's discharge plan was significantly associated with attending outpatient psychiatric appointments, regardless of the patient's level of engagement in care before admission. The differences were most pronounced for patients who had not received any outpatient care in the 6 months before admission. When an appointment was scheduled, these patients were three times more likely to follow up with care within 7 days and more than twice as likely to follow up within 30 days than were patients without a scheduled appointment.ConclusionsThe likelihood of psychiatric inpatients following up with outpatient psychiatric care was directly related to their level of outpatient care engagement before hospital admission. Even among those who had not been engaged in outpatient care, inpatient discharge planning was associated with a greater likelihood of receiving follow-up outpatient care.

ObjectiveShortened life expectancy of people with mental disorders has been attributed to medical comorbidities, yet these conditions remain under-recognized and under-treated. This study characterizes the medical demands placed on inpatient psychiatric units to help guide medical assessment and management practices in these settings.MethodsMedicaid claims records and clinician data were linked with hospital and regional data for individuals with a principal diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. A modified Elixhauser Comorbidity Index (ECI) score was calculated for each unique individual (n = 14,458). Adjusted odds ratios (AORs) of having a medical comorbidity were calculated using logistic regression analyses.Results74.9% of psychiatric inpatients had at least one medical comorbidity, including 57.5% of people ages 18-24. Higher rates of medical comorbidity were associated with older age, female gender, non-schizophrenia diagnoses, and engagement in care prior to hospitalization. Patients with medical comorbidities had lower odds (AOR 0.54; 99% CI 0.35-0.83) of being treated in hospitals with 100 or more total beds compared to smaller hospitals.ConclusionsA high prevalence of common medical diagnoses among psychiatric inpatients underscores the importance of adequate detection and medical treatment of medical comorbidities in psychiatric inpatient settings.

The BabA adhesin mediates high-affinity binding of Helicobacter pylori to the ABO blood group antigen-glycosylated gastric mucosa. Here we show that BabA is acid responsive-binding is reduced at low pH and restored by acid neutralization. Acid responsiveness differs among strains; often correlates with different intragastric regions and evolves during chronic infection and disease progression; and depends on pH sensor sequences in BabA and on pH reversible formation of high-affinity binding BabA multimers. We propose that BabA's extraordinary reversible acid responsiveness enables tight mucosal bacterial adherence while also allowing an effective escape from epithelial cells and mucus that are shed into the acidic bactericidal lumen and that bio-selection and changes in BabA binding properties through mutation and recombination with babA-related genes are selected by differences among individuals and by changes in gastric acidity over time. These processes generate diverse H. pylori subpopulations, in which BabA's adaptive evolution contributes to H. pylori persistence and overt gastric disease.

PurposeA randomized controlled trial found that patients with diabetes had lower HbA1c levels after 6 months of peer health coaching than patients who did not receive coaching. This paper explores whether the peer coaches in that trial, all low-income patients with diabetes, mastered and utilized an evidence-based health coaching training curriculum. The curriculum included 5 core features: ask-tell-ask, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling.MethodsThis paper includes the results of exams administered to trainees, exit surveys performed with peer coaches who completed the study and those who dropped out, observations of peer coaches meeting with patients, and analysis of in-depth interviews with peer coaches who completed the study.ResultsOf the 32 peer coach trainees who completed the training, 71.9% lacked a college degree; 25.0% did not graduate from high school. The 26 trainees who passed the exams attended 92.7% of training sessions compared with 80.6% for the 6 trainees who did not pass. Peer coaches who completed the study wanted to continue peer coaching work and had confidence in their abilities despite their not consistently employing the coaching techniques with their patients. Quotations describe coaches' perceptions of the training.ConclusionsOf low-income patients with diabetes who completed the evidenced-based health coaching training, 81% passed written and oral exams and became effective peer health coaches, although they did not consistently use the techniques taught.

Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated. This study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates. Of 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m2. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications. Non-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available. [ABSTRACT FROM AUTHOR]