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Todd Gilmer

Publications and source records attributed to Todd Gilmer.

15 recordsLinked to original sources
PubMed2006

Costs of community-based public mental health services for older adults: variations related to age and diagnosis.

BACKGROUND: Several studies have examined service use among older adults although, to our knowledge, none has examined costs from a systems perspective. This study examined use and costs of mental health services among older adults in San Diego County in order to determine how expenditures and modes of service varied by age cohort and psychiatric diagnosis. METHODS: Utilization data from San Diego County Adult and Older Adult Mental Health Services (AOAMHS) were used to identify older adults (age > or = 60) receiving services in the community during fiscal year 2003-2004. Cost data were derived from detailed examination of cost reports, and Medicaid fee schedules. Trends in demographic and clinical characteristics by six age cohorts were described. Multivariate models were used to estimate the relationships between costs, age, and clinical diagnosis while controlling for other demographic and clinical characteristics. Components of costs were also examined. RESULTS: Total expenditures declined from age cohorts 60-64 through ages 85 and over. Expenditures were similar, and greatest, for clients with schizophrenia and bipolar disorder, while outlays were lower for those with major depression, other psychotic disorder, other depression, anxiety, substance use disorder, and cognitive disorders. Clients diagnosed with cognitive disorder had high use of emergency services and little connection to outpatient services. CONCLUSIONS: Expenditures were related to age and clinical diagnosis. Future efforts should investigate older adults' pathways to care, and should determine whether older adults presenting in emergency services would benefit from a specialized case management program providing linkages to community based resources.

Age Factors↗
PubMed2005

Differences in clinical features and mental health service use in bipolar disorder across the lifespan.

OBJECTIVE: Because of the scarcity of research in geriatric bipolar disorder, the authors examined the prevalence, clinical features, and service use of persons with bipolar disorder among older adults treated in a large public mental health system. METHODS: From San Diego County's Adult and Older-Adult Mental Health Services database (N=34,970, fiscal year 2002-2003), the authors selected patients with bipolar disorder, divided them into three age-groups (young: age 18-39, middle-aged: age 40-59, and elderly: age 60+) and compared them on demographic, clinical, and mental health service use characteristics. RESULTS: The authors identified 2,903 patients who received services for bipolar disorder at least once during the fiscal year, accounting for a slightly lower proportion of diagnosis among elderly patients (7.0%) than middle-aged (8.7%) or younger groups (8.3%). Elderly patients were less likely to have substance use disorder comorbidity, but more likely to have a cognitive disorder diagnosis and lower global functioning scores than their younger counterparts. Elderly bipolar patients were less likely than younger groups to use inpatient, outpatient, and emergency room psychiatric care, but more likely to use case-management and conservator services. DISCUSSION: Bipolar disorder was only slightly less common among elderly patients in a large, public mental health system, compared to younger age-groups. Available clinical data revealed a mixed picture of bipolar disorder in late life, with more functional and cognitive impairment and less substance use disorder comorbidity and use of acute psychiatric services. Our findings suggest that older adults with bipolar disorder have unique mental health service needs.

Adolescent↗
PubMed2005

Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system.

OBJECTIVE: The authors examined the prevalence of and risk factors for homelessness among all patients treated for serious mental illnesses in a large public mental health system in a 1-year period. The use of public mental health services among homeless persons was also examined. METHOD: The study included 10,340 persons treated for schizophrenia, bipolar disorder, or major depression in the San Diego County Adult Mental Health Services over a 1-year period (1999-2000). Analytic methods that adjusted for potentially confounding variables were used. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness, including age, gender, ethnicity, substance use disorder, Medicaid insurance, psychiatric diagnosis, and level of functioning. Similarly, odds ratios were computed for utilization of mental health services by homeless versus not-homeless patients. RESULTS: The prevalence of homelessness was 15%. Homelessness was associated with male gender, African American ethnicity, presence of a substance use disorder, lack of Medicaid, a diagnosis of schizophrenia or bipolar disorder, and poorer functioning. Latinos and Asian Americans were less likely to be homeless. Homeless patients used more inpatient and emergency-type services and fewer outpatient-type services. CONCLUSIONS: Homelessness is a serious problem among patients with severe mental illness. Interventions focusing on potentially modifiable factors such as substance use disorders and a lack of Medicaid need to be studied in this population.

Adult↗
PubMed2005

A randomized trial of short-term acute residential treatment for veterans.

OBJECTIVE: A variety of alternatives to acute psychiatric hospital care have been developed over the past several decades. including San Diego's short-term acute residential treatment (START) program, now comprising a certified and accredited network of six facilities with a total of 75 beds. This study compared outcomes, patient satisfaction, and episode costs for a sample of 99 veterans who received acute care either at an inpatient unit at a Department of Veterans Affairs (VA) hospital or at a START facility. METHODS: Consenting participants were randomly assigned to one of the two treatment settings. Follow-up was conducted at two months. During the follow-up period, participants received treatment as usual. Multiple standardized measures were used to maximize validity in assessing symptoms, functioning, and quality of life. RESULTS: Participants who were treated in either a hospital or the START program showed significant improvement between admission, discharge, and two-month follow-up, with few statistically significant differences between the groups in symptoms and functioning. There was some evidence that START participants had greater satisfaction with services. Mean costs for the index episode were significantly lower for START participants (65 percent lower) than for those who were treated in the hospital. CONCLUSIONS: The results of this study suggest that the START model provides effective voluntary acute psychiatric care in a non-hospital-based setting at considerably lower cost. Efforts to replicate and evaluate the model at additional locations merit attention.

Acute Disease↗
PubMed2005

Children welcome, adults need not apply: changes in public program enrollment across states and over time.

This article describes changes in the extent of public health insurance coverage for low-income children and adults from 1979 through 2001. Although previous research has demonstrated that public coverage among children has increased substantially during the past 20 years, our work shows that almost all of the increase has occurred among children in families with incomes between 100% and 200% of the federal poverty level (FPL), with little change among children in families with incomes below 100% of FPL. In contrast to the increase in public coverage among children, there has been virtually no change in the generosity of public programs for low-income adults. The overall stability of public coverage for adults masks substantial changes at the state level: public coverage for adults increased substantially in Tennessee, Vermont, Arizona, and other states that implemented Section 1115 Medicaid waivers, while declining in New York, California, and many Rust Belt states.

Adult↗
PubMed2003

Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial.

CONTEXT: Ethics consultations increasingly are being used to resolve conflicts about life-sustaining interventions, but few studies have reported their outcomes. OBJECTIVE: To investigate whether ethics consultations in the intensive care setting reduce the use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, as well as the reactions to the consultations of physicians, nurses, and patients/surrogates. DESIGN: Prospective, multicenter, randomized controlled trial from November 2000 to December 2002. SETTING: Adult intensive care units (ICUs) of 7 US hospitals representing a spectrum of institutional characteristics. PATIENTS: Five hundred fifty-one patients in whom value-related treatment conflicts arose during the course of treatment. INTERVENTIONS: Patients were randomly assigned either to an intervention (ethics consultation offered) (n = 278) or to usual care (n = 273). MAIN OUTCOME MEASURES: The primary outcomes were ICU days and life-sustaining treatments in those patients who did not survive to hospital discharge. We examined the same measures in those who did survive to discharge and also compared the overall mortality rates of the intervention and usual care groups. We also interviewed physicians and nurses and patients/surrogates about their views of the ethics consultation. RESULTS: The intervention and usual-care groups showed no difference in mortality. However, ethics consultations were associated with reductions in hospital (-2.95 days, P =.01) and ICU (-1.44 days, P =.03) days and life-sustaining treatments (-1.7 days with ventilation, P =.03) in those patients who ultimately did not survive to discharge. The majority (87%) of physicians, nurses, and patients/surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts. CONCLUSION: Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU.

Adult↗
PubMedDate not supplied

Insuring low-income adults: does public coverage crowd out private?

During the mid-1990s Minnesota, Washington State, Oregon, and Tennessee implemented programs to provide subsidized health insurance for low-income persons who were not previously eligible for Medicaid. We estimate the effects of these programs on the health insurance status of low-income adults in these states. We find that among persons with family incomes below 100 percent of the federal poverty level, subsidized public coverage reduced the number of uninsured persons with very little effect on private coverage rates. Among persons with income between 100 percent and 200 percent of FPL, public coverage reduced the number of uninsured persons and crowded out some private insurance. The partial successes achieved by these programs should be kept in perspective: Even after program implementation, approximately 30 percent of low-income adults in the four states were uninsured.

Adult↗
PubMedDate not supplied

The costs of nonbeneficial treatment in the intensive care setting.

Ethics consultations have been shown to reduce the use of "nonbeneficial treatments," defined as life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, when treatment conflicts occurred in the adult intensive care unit (ICU). In this paper we estimated the costs of nonbeneficial treatment using the results from a randomized trial of ethics consultations. We found that ethics consultations were associated with reductions in hospital days and treatment costs among patients who did not survive to hospital discharge. We conclude that consultations resolved conflicts that would have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU instead of focusing on more appropriate comfort care.

Adult↗
PubMedDate not supplied

Ethics and futility.

Explore the source record for details and available documents.

Critical Care↗
PubMedDate not supplied

The kindness of strangers: community effects on the rate of employer coverage.

The rate of employer-sponsored insurance (ESI) varies greatly across states. We analyze the factors that account for that variation. We find that the likelihood that a worker is covered by ESI depends on workers' own characteristics and also on those of other workers in the same metropolitan statistical area. Further, in almost all states the percentage of workers covered by ESI is close to the predicted level of coverage, which suggests that state policies that could affect insurance coverage have had little net effect on ESI rates. Hawaii is an exception: Its mandate on employers to offer coverage results in a rate of ESI that is much higher than expected.

Adult↗
PubMedDate not supplied

It's the premiums, stupid: projections of the uninsured through 2013.

Increases in the cost of health care from 1979 to 1999 accounted for the decline in health insurance coverage that occurred during that time period, as our earlier work demonstrated. Here we examine whether the model we presented adequately accounts for the observed changes in health insurance coverage from 1999 through 2002, and we show that the model accurately predicted the increase in uninsured people during that time period. Using the model and projections for national health spending, we project that the number of nonelderly uninsured Americans will grow from forty-five million in 2003 to fifty-six million by 2013.

Forecasting↗
PubMedDate not supplied

Health plan disenrollment in a choice-based Medicaid managed care program.

Consumer decisions to switch health plans have implications for quality of care and risk selection. We examine factors related to time to disenrollment in a Medicaid managed care program where beneficiaries face a menu of plans and can change plans every month. Several findings have direct policy relevance. Families and individuals who make active choices upon entering the program are at substantially lower risk of disenrollment than those who are auto-assigned. Interactions between enrollee ethnicity and provider language proficiency suggest that enrollee satisfaction depends on the cultural competence of providers. Differential disenrollment by risk status results in adverse retention for certain types of plans.

Adult↗