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Biomedical subjects

Joseph P Morrissey

Publications and source records attributed to Joseph P Morrissey.

At least 19 recordsLinked to original sources
PubMed2007

Use of autism-related services by families and children.

This paper describes approaches to care and associated service use by families with a child with autism. A combined telephone and self-administered survey was completed by 301 families with a child, 8 years old or younger, in North Carolina, during the winter of 2003-2004. Findings indicate that 66% of families used one or more approach to care and there was a significant (p < 0.05) association between approach and the pattern of service use. There appears to be a distinctive set of services associated with each approach to care, but with overlap between them. Speech/language therapy at school was the most frequently used service and also identified as the best service. The majority (81%) of families reported they were satisfied with services.

Autistic Disorder↗
PubMed2007

A comparison of assertive community treatment and intensive case management for patients in rural areas.

OBJECTIVE: This article reviews the evidence for the effectiveness of community-based services for rural areas, specifically assertive community treatment and intensive case management. Service delivery to persons with severe mental illness in rural areas is challenged by low population densities, limited services, and shortages of professionals. METHODS: A comprehensive literature search identified six studies of rural assertive community treatment, only two of which were controlled studies, and four rural intensive case management studies, only one of which was a controlled study. Assertive community treatment would seem ideally suited to areas lacking services because of its self-contained multidisciplinary treatment team approach. However, rural programs have been forced to make several adaptations to the assertive community treatment model, including smaller teams, less comprehensive staff, and less intensive services. There is no published evidence that these adaptations are able to produce the same results as full-fidelity teams. Some believe that intensive case management may be an alternative to assertive community treatment in rural settings because intensive case management emphasizes individual caseloads, fewer staff, less intensive contacts, and brokered services. CONCLUSIONS: The evidence suggests that intensive case management programs are effective only in community settings where there is an ample supply of treatment and support services. To build the evidence base for the effectiveness of these models, much more attention needs to be focused on evaluating the current wave of assertive community treatment and intensive case management dissemination in rural areas.

Case Management↗
PubMed2006

Transitions between the public mental health system and jail for persons with severe mental illness: a Markov analysis.

Proposed changes to the mental health care system are usually debated in terms of either health benefits or costs savings. However, because of the extensive intersection between the mental health system and the criminal justice system, changes in the organization and financing of mental health services may change the jail detention rate. We analyze jail incarcerations for felonies and non-felonies following the start of a public managed mental health care program in King County, Washington (including Seattle). We analyze unique data that tracks individuals in and out of the public mental health, Medicaid, and criminal justice systems for 1993-1998. In this manuscript we examine individuals with severe mental illness who were enrolled in the Washington state Medicaid program. The final sample size has monthly observations on 6766 unique individuals aged 18-64. We estimate Markov models of the monthly transition probabilities among living in the community with no public mental health treatment, receiving inpatient or outpatient mental health or substance abuse services, or being in jail for either a felony or non-felony charge. The transition probabilities are adjusted for demographics and policy changes that occurred during our study period. There is little evidence of any change in the jail detention rate for severely mentally ill users of the county mental health system in contrast with other SMI individuals following the public managed care program.

Acute Disease↗
PubMed2006

Assessing delayed effects of a multi-site system intervention for homeless persons with serious mental illness.

ACCESS demonstration sites were followed for an additional two years beyond the scheduled four-year evaluation to assess whether any delayed effects had occurred in system and project integration. For system integration, findings indicate that there was a sharp increase between Wave 3 (1998) and Wave 4 (2000), but experimental and comparison sites had identical trends. For project integration, experimental sites at Wave 4 sustained the high level of integration achieved at Wave 3, but the comparison sites achieved the same level as the experimental sites at Wave 4, through an abrupt increase in their scores. The absence of delayed effects is likely due to diffusion of the interventions to comparison sites both in the latter stages of the demonstration and immediately afterwards. Further, aggressive lobbying on the part of ACCESS program managers to generate local and state support to sustain their services following the termination of federal funding, had an integrating effect thereby creating linkages among comparison site agencies. Implications of these findings for policy and further research are highlighted.

Efficiency, Organizational↗
PubMed2006

Assessing the service linkages of substance abuse agencies with mental health and primary care organizations.

Fragmentation of substance abuse treatment represents a major barrier to effective treatment for individuals with cooccurring substance abuse and mental and physical health disorders. Linkages of substance abuse treatment organizations with primary care and mental health agencies are widely considered to be a feasible way to integrate services. In this study, we analyzed information collected from a national sample of 62 outpatient substance abuse treatment units (OSATs) to understand the extent of services linkages in these organizations and to identify facilitators and barriers to service linkages. Results showed that OSATs had limited service linkages with primary care and mental health providers. The cited barriers to linkages included clients' financial problems, managed care restrictions, and limited organizational capacity. Onsite service provision was implemented in some OSATs. The pattern of service linkages in OSATs appeared to reflect the health needs of substance abuse clients.

Humans↗
PubMed2006

How many assertive community treatment teams do we need?

OBJECTIVE: Assertive community treatment (ACT) reduces hospitalizations for persons with severe mental illness. However, not everyone who needs ACT receives it. Without empirical guidelines for ACT planning, communities are likely to underestimate or overestimate the number of teams they need; thus the capacity of the programs will not meet current needs. In this study, administrative data were used to develop empirical estimates for the number of required ACT teams. These estimates were then used to examine current conceptual guidelines for developing the number of ACT teams that communities need. METHODS: Administrative data from a large, urban county were used to enumerate all persons with a severe mental illness who had three or more hospitalizations within one year (ACT eligible). RESULTS: Fifty-one percent of persons with a severe mental illness were found to be eligible for ACT (743 of 1,453 persons). This figure represents 2.2 percent of the county's mental health users and .06 percent of its adult population. CONCLUSIONS: Communities should develop enough ACT teams to serve approximately 50 percent of their populations of persons with severe mental illness or roughly .06 percent of their adult populations.

Adolescent↗
PubMed2006

Assessing gaps between policy and practice in Medicaid disenrollment of jail detainees with severe mental illness.

OBJECTIVE: This prospective cohort study in two large metropolitan jail systems examined whether Medicaid disenrollment policies for persons detained in jail were enforced. The extent to which persons with severe mental illness lost their Medicaid benefits while detained was determined. METHODS: Mailed questionnaires to state Medicaid directors in 2000 yielded a 95 percent response rate. Directors responded to questions about procedures that are followed when enrollees become inmates in public institutions. In addition, community mental health service records, jail detention records, and Medicaid enrollment records were linked in King County (Seattle) and in Pinellas County (Clearwater and St. Petersburg), Florida, to identify persons with severe mental illness who were incarcerated at any time during a two-year period (1996-1998 in King County and 1998-2000 in Pinellas County). The samples consisted of 1,816 persons representing 4,482 detentions in King County and 1,210 persons representing 2,878 detentions in Pinellas County. Detentions were used as the unit of analysis to determine how often Medicaid disenrollment occurred during jail incarceration. RESULTS: The stated policy in many states, including Florida and Washington, is to terminate Medicaid benefits upon incarceration, but termination occurred for only 3 percent of the detainees enrolled in Medicaid in each county. In both counties, in 97 percent of the detentions, persons who had Medicaid at entry also had it upon release. In both counties, the 3 percent who lost Medicaid while jailed had longer jail stays (three to five months compared with 16 to 30 days). CONCLUSIONS: Stated policies do not align with actual Medicaid disenrollment of persons with severe mental illness who become incarcerated. In most instances, short jail stays allowed detainees with severe mental illness to retain their Medicaid benefits.

Adult↗
PubMed2006

Medicaid enrollment and mental health service use following release of jail detainees with severe mental illness.

OBJECTIVE: This study assessed the extent to which Medicaid enrollment increased access to and use of services by persons with severe mental illness after their release from jail. METHODS: A prospective cohort design was used that linked administrative data from several agencies in two large urban areas: King County (Seattle) from 1996 to 1998 and Pinellas County (Clearwater and St. Petersburg), Florida, from 1998 to 2000. Access to and use of community mental health services within 90 days after release from jail was examined, depending on whether persons were enrolled in Medicaid at the time of their release. All analyses were based on detentions, rather than unique persons. The effects of Medicaid status (enrolled or not enrolled) on four dependent variables (probability of use, days to first service, number of services used, and rate of service use) were estimated separately for each county. RESULTS: A total of 1,210 persons who had 2,878 detentions were identified in Pinellas County: 2,215 of these detentions represented persons with Medicaid and 663 represented those without Medicaid. For King County, the corresponding numbers were 1,816 persons and 4,482 detentions: 2,752 of these detentions represented persons with Medicaid and 1,730 represented those without Medicaid. In both counties, those who had Medicaid at the time of their release were more likely to use services (p < .001), accessed community services more quickly (p < .001), and received more days of services (p < .001) than those without Medicaid. CONCLUSIONS: Medicaid enrollment enhanced receipt of community services after jail release in these two large urban counties. These are the best currently available data, and the data suggest that efforts to enroll persons with severe mental illness in Medicaid and ensure enrollment upon jail release will improve their access to and receipt of community-based services after release.

Adult↗
PubMed2005

Outcomes for women with co-occurring disorders and trauma: program-level effects.

Program-level effects at 6 months are reported from meta-analysis of a nine-site quasi-experimental study of comprehensive, integrated, trauma-informed, and consumer-involved services for women who have mental health problems, substance use disorders, and who have experienced interpersonal violence. The average weighted effect size is significant for the treatment condition for improved post-traumatic symptoms (p < 0.02), drug use problem severity (p < 0.02), and nearly significant for mental health symptoms (p < 0.06). There is significant heterogeneity in effect sizes across sites. Program-level variables were examined in an effort to explain this heterogeneity. The findings indicate that sites which provided significantly more integrated counseling produced more favorable results in mental health symptoms (p < 0.01) and both alcohol (p < 0.001) and drug use problem severity (p < 0.001). The same trend is observable for reductions in post-traumatic stress symptoms, although the difference does not attain statistical significance.

Adult↗
PubMed2005

Service costs for women with co-occurring disorders and trauma.

Several aspects of costs related to health care and other service use at 6-month follow-up are presented for women with co-occurring mental health and substance abuse disorders with histories of physical and/or sexual abuse receiving comprehensive, integrated, trauma-informed and consumer/survivor/recovering person-involved interventions (n = 1023) or usual care (n = 983) in a nine-site quasi-experimental study. Results show that, controlling for pre-baseline use, there are no significant differences in total costs between participants in the intervention condition and those in the usual care comparison condition, either from a governmental (avg. US dollars 13,500) or Medicaid reimbursement perspectives (avg. just over US dollars 10,000). When combined with clinical outcomes analyzed in other works in this issue by Cocozza et al. (2005) and Morrissey et al. (2005), which favored the intervention sites, these cost findings indicate that the treatment intervention services are cost-effective as compared with the usual care received by women at the comparison sites.

Adult↗
PubMed2005

Outcomes for women with co-occurring disorders and trauma: program and person-level effects.

Six-month outcomes are evaluated from a 9-site quasi-experimental study of women with mental health and substance use disorders who have experienced physical or sexual abuse who enrolled in either comprehensive, integrated, trauma-informed, and consumer/survivor/recovering person-involved services (N = 1023) or usual care (N = 983). Mental health, post-traumatic stress symptoms, and substance use outcomes are assessed with multilevel regression models, controlling for program and personal characteristics. Person-level variables predict outcomes independent of intervention condition and, to a small extent, moderate intervention and program effects. In sites where the intervention condition provided more integrated counseling than the comparison condition, there are increased effects on mental health and substance use outcomes; these effects are partially mediated by person-level variables. These results encourage further research to identify the longer-term effects of integrated counseling for women with co-occurring disorders and trauma histories.

Adult↗
PubMed2005

Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders.

OBJECTIVE: Women with co-occurring mental health and substance use disorders frequently have a history of interpersonal violence, and past research has suggested that they are not served effectively by the current service system. The goal of the Women, Co-occurring Disorders, and Violence Study was to develop and test the effectiveness of new service approaches specifically designed for these women. METHODS: A quasi-experimental treatment outcome study was conducted from 2001 to 2003 at nine sites. Although intervention specifics such as treatment length and modality varied across sites, each site used a comprehensive, integrated, trauma-informed, and consumer-involved approach to treatment. Substance use problem severity, mental health symptoms, and trauma symptoms were measured at baseline, and follow-up data were analyzed with prospective meta-analysis and hierarchical linear modeling. RESULTS: A total of 2,026 women had data at the 12-month follow-up: 1,018 in the intervention group and 1,008 in the usual-care group. For substance use outcomes, no effect was found. The meta-analysis demonstrated small but statistically significant overall improvement in women's trauma and mental health symptoms in the intervention relative to the usual-care comparison condition. Analysis of key program elements demonstrated that integrating substance abuse, mental health, and trauma-related issues into counseling yielded greater improvement, whereas the delivery of numerous core services yielded less improvement relative to the comparison group. A few person-level characteristics were associated with increases or decreases in the intervention effect. These neither moderated nor supplanted the effects of integrated counseling. CONCLUSIONS: Outcomes for women with co-occurring disorders and a history of violence and trauma may improve with integrated treatment.

Adult↗
PubMed2005

Service use and costs for women with co-occurring mental and substance use disorders and a history of violence.

OBJECTIVES: This study examined the 12-month cost of the array of services used by women with co-occurring mental health and substance use disorders and a history of violence and trauma who participated in the Women, Co-occurring Disorders, and Violence Study (WCDVS). The study compared costs of the intervention and external services for women in the WCDVS intervention in outpatient and residential settings-which provided comprehensive, integrated, and trauma-informed services-with the costs for women in the usual-care comparison group. The study also compared costs with recorded clinical outcomes. METHODS: Costs of service use were examined for 2,026 women who participated in the WCDVS (N=1,018) and in the comparison group (N=1,008). Women were interviewed three, six, nine, and 12 months after baseline about any service use in the past three months. Costs for these services, along with indirect costs (participants' time and transportation) were estimated by using a variety of sources. A number of cost estimates were analyzed by using either ordinary least squares regression or two-part models. RESULTS: The average participant had almost 43,000 dollars in costs related to their service use during the 12 months after baseline. Women in the intervention group had lower service costs and higher overall costs than those in the comparison group, but the null hypotheses of no difference in any cost measure between groups was not rejected. Also, the null hypothesis of no difference in the probability of accessing services external to the study intervention was not rejected. CONCLUSIONS: Because no differences were detected in costs but improvements were seen in clinical outcomes, the interventions offered in the WCDVS may be more efficient than usual care.

Adult↗
PubMed2005

Assessment of Medicaid managed behavioral health care for persons with serious mental illness.

OBJECTIVES: This five-site study compared Medicaid managed behavioral health programs and fee-for-service programs on use and quality of services, satisfaction, and symptoms and functioning of adults with serious mental illness. METHODS: Adults with serious mental illness in managed care programs (N=958) and fee-for-service programs (N=1,011) in five states were interviewed after the implementation of managed care and six months later. After a multiple regression to standardize the groups for case mix differences, a meta-analysis using a random-effects model was conducted, and bioequivalence methods were used to determine whether differences were significant for clinical or policy purposes. RESULTS: A significantly smaller proportion of the managed care group received inpatient care (5.7 percent compared with 11.5 percent). The managed care group received significantly more hours of primary care (4.9 compared with 4.5 hours) and was significantly less healthy. However, none of these differences exceed the bioequivalence criterion of 5 percent. Managed care and fee for service were "not different but not equivalent" on 20 of 34 dependent variables. Cochrane's Q statistic, which measured intersite consistency, was significant for 20 variables. CONCLUSIONS: Managed care and fee-for-service Medicaid programs did not differ on most measures; however, a lack of sufficient power was evident for many measures. Full endorsement of managed care for vulnerable populations will require further research that assumes low penetration rates and intersite variability.

Adult↗
PubMed2005

Effects of antipsychotic medication on psychiatric service utilization and cost.

BACKGROUND: Based on randomized clinical trials, consensus has been emerging that the first line of treatment for individuals with psychotic disorders should be the newer atypical or second generation antipsychotic medications rather than the older neuroleptics. Given that acquisition costs of atypical antipsychotics are generally higher than typical antipsychotics, uncertainty exists whether the newer atypicals are cost effective alternatives when used in ordinary practice settings. AIMS OF THE STUDY: The introduction of newer atypical antipsychotic agents has prompted evaluation of their overall effectiveness in reducing health care costs given their higher acquisition costs. This paper focuses on the effects of differing classes of atypical versus typical antipsychotic medications on psychiatric service utilization and cost for persons with serious mental illness treated in usual practice settings. METHODS: Descriptive statistics are used to compare patient characteristics, service rates and costs across psychotropic medication groups. Prediction equations employing ordinary least squares regression models are used to explain variation in cost due to pharmacy group membership controlling for demographics, clinical diagnoses and symptoms. Subjects were 338 Medicaid clients with serious mental illness from Florida, Pennsylvania and Oregon treated in ordinary clinical settings. Resource utilization and costs were operationalized using administrative databases to measure consumption of treatment services and pharmaceuticals for a six month period. RESULTS: Inpatient service use was significantly higher for individuals on atypical only and combination atypical/typical medications compared to those on typical medications only, whereas outpatient use was highest for those on typicals. Furthermore, six-month costs for both pharmacy and psychiatric services were significantly greater for persons in the atypical only (USD 6528) and combination typical/atypical groups (USD 6589) compared to those on typicals only (USD 3463). There were still significantly higher costs associated with atypical only and the combination typical/atypical users after multivariate controls were used. DISCUSSION: This study showed that Medicaid clients in community settings using atypical only and typical/atypical combination medications had the highest costs both in pharmacy and service use when compared to those on typical only medications. However, this study design does not allow us to ascribe a causal relationship between medication group and service costs. Given that olanzapine was the most recent medication in the compendium of available drugs at the time of this study, it is possible that those in the olanzapine only group were failing on other drugs. Caution must be used in drawing policy implications regarding cost effectiveness of newer medications since individuals who are getting the newer atypical or combination medications in community mental health center settings may be unstable on the older medications. IMPLICATIONS FOR FUTURE RESEARCH: A longer follow-up period is needed to determine if the cohort remaining on current atypical medications stabilize over time while those taking the newest drug on the market become the most costly population.

Adult↗
PubMed2004

Cost shifting to jails after a change to managed mental health care.

OBJECTIVE: To determine whether managed mental health care for Medicaid enrollees in King County, Washington, has led to indirect cost-shifting to substitute treatments, such as jails and state mental hospitals that are free goods to providers. DATA SOURCES: Complete service records for 47,300 adults who used at least one of the following systems from 1993 to 1998: King County jail system, Medicaid, or the King County mental health system. Data were also obtained from the Washington State Hospital System. STUDY DESIGN: A quasi-experimental analysis that compares the difference in outcomes between the pre- and post-managed care periods for Medicaid enrollees compared to non-Medicaid enrollees. The outcomes-jail costs, state hospital costs, and county outpatient mental health costs-were estimated with two-part difference-in-differences models. The regressions control for person-level fixed effects on up to 66 months of data per person. DATA COLLECTION METHODS: Administrative data were collected from the jail, Medicaid, and mental health systems, then merged and cleaned. Additional data on costs were obtained in interviews. PRINCIPAL FINDINGS: There is a striking increase in the probability of jail use for persons on Medicaid following the introduction of managed care. There was a significant decrease in expenditures in the county mental health system for outpatient care. CONCLUSIONS: Managed care led to indirect cost-shifting, probably through poor access to services, which may have led to an increased probability of jail detention.

Adult↗