Literature Collection

OBJECTIVE: Characterize the association between Medicare Accountable Care Organizations' (ACOs) behavioral health integration capability and quality and utilization among adults with serious mental illness (SMI). BACKGROUND: Controlled research supports the efficacy of integrating physical and mental health care for adults with SMI, yet little is known about the organizations integrating care and associations between integration capability and quality. METHODS: We surveyed Medicare ACOs (2017-2018 National Survey of ACOs, response rate 69%) and linked responses to 2016-2017 fee-for-service Medicare claims for beneficiaries with SMI. We examined the cross-sectional association between ACO-reported integration capability (tertiles of a 14-item index) and 7 patient-level quality and utilization outcomes. We fit generalized linear models for each outcome as a function of ACO integration capability, adjusting for ACO and beneficiary characteristics. RESULTS: Study sample included 274,928 beneficiary years (199,910 unique beneficiaries) attributed to 265 Medicare ACOs. ACOs with high behavioral health integration capability (top-tertile) served more dual-eligible beneficiaries (67.8%) than bottom-tertile (63.7%) and middle-tertile ACOs (63.3%). Most beneficiaries received follow-up 30 days after mental health hospitalization and chronic disease monitoring-exceeding national quality benchmarks-but beneficiaries receiving care from top-tertile (vs bottom-tertile) ACOs were modestly less likely to receive follow-up [-2.17 percentage points (pp), P < 0.05], diabetes monitoring (-2.19 pp, P < 0.05), and cardiovascular disease monitoring (-6.07 pp, P < 0.05). Integration capability was not correlated with utilization. CONCLUSIONS: ACOs serving adults with substantial physical and mental health needs were more likely to report comprehensive integration capability but were not yet meeting the primary care needs of many adults with SMI.

BACKGROUND: Medicare serves 65 million Americans aged 65+, with 3.7% having co-occurring mental health and substance use disorders. Despite evidence supporting integrated care, fragmented Medicare policies result in higher readmissions and lower treatment completion rates for this vulnerable population. PURPOSE: To analyze Medicare policies using the Integration Continuum Framework and identify nursing practice and policy implications for older adults with dual diagnoses. METHODS: Systematic review of Medicare policy documents (2010-2023) analyzed through the Integration Continuum Framework across clinical, financial, and administrative dimensions. DISCUSSION: Medicare policies predominantly reflect minimal integration (Levels 1-2). Only 17.3% of beneficiaries with co-occurring disorders receive coordinated care, requiring visits to 3.7 providers across 2.8 facilities compared to 1.9 providers at 1.6 facilities for single diagnoses. The Collaborative Care Model achieves Level 3 integration but excludes substance use disorders, limiting comprehensive care. CONCLUSION: Medicare's fragmented approach creates significant coordination challenges. Nurses are uniquely positioned to bridge these gaps through screening protocols, care navigation, and leadership initiatives. Policy reforms including expanding the Collaborative Care Model to include substance use disorders, eliminating same-day billing restrictions, and streamlining documentation represent pathways toward comprehensive Level 4-5 integration, ultimately improving outcomes for older adults with dual diagnoses.

INTRODUCTION: Medication assisted treatment (MAT) for opioid use disorder (OUD) saves lives and enhances quality of life for people in recovery. However, only a small percentage of people eligible for MAT in the United States receive treatment, and among those who do seek treatment, retention is a challenge. This study aims to understand factors that help individuals enter and stay in MAT from the perspective of those in recovery. The patient perspective is vital in efforts to improve care delivery and best support individuals in treatment. METHODS: Survey development was driven by a review of current peer-reviewed literature plus information gained through 3 semi-structured interviews and follow-up discussions with 5 individuals who have lived experience in MAT, termed Participant Advisors. Survey questions focused in part on MAT participants' opinions relating to program policies such as drug testing, relapse protocols, duration of treatment, participant use of anti-anxiety medications and marijuana, and requirements for attendance in peer recovery groups such as Narcotics Anonymous and Alcoholics Anonymous. Responses were collected from West Virginia-based MAT programs from February through August 2021, with 1700 surveys distributed to 21 MAT programs. RESULTS: At the close of data collection, 225 survey responses, including over 500 free-text comments, were received (13.2% response rate). Most (n = 207, 95%) were currently in a MAT program and most (n = 187, 88.6%) reported using buprenorphine/naloxone for MAT, though participants reported having used other medications for treatment of OUD as well. Questions about how long a person should have MAT prescribed, how long they should be able to stay in treatment, whether they can use marijuana or anti-anxiety drugs while in treatment, and whether they should use a 12-step program generated mixed opinions. Findings strongly support consideration of individual situations and shared decision-making with providers.