Evaluating the Impact of Clinical Alerts Generated from Medicaid Claims Data

描述（申请人提供）：在最近几起涉及纽约市精神病患者的高度宣传的暴力事件之后，纽约精神卫生办公室开始实施一项政策，利用行政数据来确定纽约市因精神病致残的最脆弱人群中明显的护理中断和不断升级的服务需求，总体目标是促进公共精神卫生系统及时采取干预措施。与纽约市合作，纽约州已拨款1300万美元建立以市镇为基础的护理监测小组，负责在医疗补助索赔中的服务使用（或不使用）模式表明高需求个人的护理存在问题时发出“临床警报”。这一政策举措代表了纽约州的一个显著转变，并有可能改变所有公共精神卫生当局使用索赔数据的方式。拟议的项目将描述这一重要的纽约州/纽约市政策变化对向最需要的严重精神疾病患者提供护理的机会、成本、质量和结果的影响。本申请建议使用来自纽约州和宾夕法尼亚州（PA）的汇总医疗补助索赔数据，以检查医疗补助索赔数据生成的“临床警报”对纽约市精神科急诊服务的连续性和使用的影响。我们假设，这种新的干预措施将减少与“临床警报”相关的服务模式的可能性，并增加门诊护理的使用后，发出这些警报。我们将研究4年期间（从干预开始前2年到干预开始后2年）医疗补助的服务使用数据，并将使用PA和纽约北部（UNY）匹配目标队列的数据来控制时间趋势。拟议项目的具体目标是：目标1：评估临床警报是否减少了使用精神卫生和药物滥用服务方面的差距。目的#2：评估临床警报是否减少填补精神药物的差距。目的#3：评估临床警报是否减少急诊室和住院服务的使用。目标4：评价临床警报对服务成本的影响。总之，这个应用程序描述了一个时间紧迫的机会，以经验和前瞻性地研究一个大型公共精神卫生系统的重大新政策举措。拟议的项目将研究一种模式，利用二级数据来确定可能预测风险增加的服务模式，触发干预措施以预防进一步的风险，并在非常多样化的环境中使用个性化信息。这项研究的结果将告知PA和UNY（比较条件）以及全国范围内的公共精神卫生当局，使用索赔数据生成临床警报的好处。 公共卫生相关性：所有州都面临着改善严重精神疾病患者护理的挑战，这些患者经常使用高强度的精神卫生服务，如精神病急诊室和精神病住院治疗，但不接受门诊治疗。纽约州已开始一个项目，利用行政数据（例如，Medicaid索赔），以标记具有服务模式的高需求个体，表明需要及时的临床干预。对这一举措的影响进行评估将对所有州精神卫生当局和刑事司法系统以及各地的精神卫生倡导者具有重大的政策意义，他们长期以来一直要求加强对精神卫生系统高风险人员的护理监督。

DESCRIPTION (provided by applicant): Following several recent, highly publicized violent incidents involving individuals with psychiatric illnesses in New York City (NYC), the New York State (NYS) Office of Mental Health began a policy of using administrative data to identify apparent interruptions in care and escalating need for services among targeted cohorts of the most vulnerable individuals disabled by psychiatric illnesses in NYC, with the overall aim of facilitating timely interventions by the public mental health system. In concert with NYC, NYS has allocated $13 million to create borough-based Care Monitoring Teams charged with responding to "clinical alerts" issued when a pattern of service use (or non-use) in Medicaid claims suggests a problem in care for high- need individuals. This policy initiative represents a marked shift for the State of New York, and has the potential to transform the way that all public mental health authorities use claims data. The proposed project will describe the impact of this critical NYS/NYC policy change on access to and cost, quality and outcomes of care provided to the neediest population of individuals with serious mental illness. This application proposes to use pooled Medicaid claims data from NYS and Pennsylvania (PA) to examine the impact of the "clinical alerts" generated by Medicaid claims data on continuity of care and use of psychiatric emergency services in NYC. We hypothesize that this new intervention will reduce the likelihood of the service patterns associated with "clinical alerts", and also increase the use of outpatient care following the issuance of those alerts. We will look at service use data from Medicaid over a 4 year period (from 2 years prior to 2 years after the intervention begins), and will use data from matched targeted cohorts in PA and Upstate New York (UNY) to control for temporal trends. The specific aims of the proposed project are: Aim #1: To evaluate whether clinical alerts reduce gaps in using mental health and substance abuse services. Aim #2: To evaluate whether clinical alerts reduce gaps in filling psychotropic medications. Aim #3: To evaluate whether clinical alerts reduce use of emergency room and inpatient services. Aim #4: To evaluate the impact of clinical alerts on cost of services. In sum, this application describes a time-critical opportunity to empirically and prospectively study a major new policy initiative in a large public mental health system. The proposed project will study a model for using secondary data to identify service patterns that may predict increased risk, triggering interventions to preempt further risk, and using personalized information in a very diverse setting. Results from this study will inform public mental health authorities in PA and UNY (the comparison conditions) as well as nationwide, of the benefit of using claims data to generate clinical alerts. PUBLIC HEALTH RELEVANCE: All states face challenges in improving care for individuals with serious mental illness who are frequent users of high intensity mental health services such as psychiatric emergency room and psychiatric hospitalization yet not engaged in outpatient treatment. New York State has embarked on a project to use administrative data (e.g., Medicaid claims), to flag high need individuals with service patterns suggesting the need for prompt clinical intervention. An evaluation of the impact of this initiative would be of great policy interest to all state mental health authorities and criminal justice systems, as well as mental health advocates everywhere who have long requested greater oversight of care for individuals at high risk of detrimental disengagement from the mental health system.