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Current and Completed Projects
A comparison of training methods for dissemination
Rinad Beidas, PhD (sponsored by Philip Kendall, PhD)
Data Sources: primary data
Project Dates: 2009-2010
Funding Source: NIMH F31 08333 2009-2010
This study evaluated the efficacy of three brief workshops and the impact of ongoing consultation following training. Cognitive-behavior therapy (CBT) for youth anxiety, an empirically supported treatment, was used as the exemplar. Participants were randomized to one of three one-day workshops to examine the efficacy of routine training (training-as-usual), computer training (computerized version of training-as-usual), and augmented training (training that emphasized active learning and principles). After training, all participants received 3 months of ongoing consultation that included case consultation, didactics, and problem-solving around implementation barriers. Participants were 115 community therapists (age M = 35.9 years; 90.4% female). Outcome measures included the Adherence and Skill Checklist, used for rating adherence and skill based on a performance-based role-play, a knowledge test, and the Training Satisfaction Scale. All three workshops resulted in limited gains in therapist adherence, skill, and knowledge. There was no significant effect of workshop on adherence, skill or knowledge from pre- to post-training. Participants were more satisfied with augmented and routine training when compared to computer training. Most importantly, number of consultation hours following training significantly predicted higher therapist adherence and skill at 3-month follow-up. The findings suggest that training alone does not result in therapist behavior change. The inclusion of ongoing consultation is critical to influencing therapist adherence and skill. Implications for implementation science and mental health services research will be discussed. (Beidas, Edmunds, Marcus, & Kendall, 2012; Beidas, Mychailyszyn, Edmunds, Khanna, Downey, & Kendall, 2012).
Social and Behavioral Science Research Network (SBSRN)
In November 2005 a small group of behavioral and social sciences investigators from the Penn and Emory CFARs began planning for the establishment of a network between scientists involved in HIV prevention and treatment research within the CFAR program. The purpose of this network was threefold. First, it was intended to foster multi-site collaborations between Behavioral and Social Scientists. Second, it was intended to share strategies on how Behavioral and Social Scientists could be better integrated with basic and clinical scientists. Finally, the SBSRN was explicitly organized to provide a forum for the exchange of the most recent information in the behavioral and biomedical sciences regarding HIV/AIDS and to mentor the next generation of behavioral social scientists engaged in research surrounding HIV prevention and treatment. It is hoped that combining the intellectual capital and synergies among the community of scientists engaged in this work will invigorate state-of-the-art science in this area. In the NIH roadmap, the "research teams of the future" are described as problem-oriented, multidisciplinary and interdisciplinary teams. We believe the SBSRN provides the foundation upon which these teams can be built and directed toward HIV research. Building on the success of the first five SBSRN Scientific Meetings (2006 – Penn, 2007 – UAB, 2008 – U of Washington, 2009 – Harvard/Brown, 2010 – Emory, 2012 – Duke/UNC) the Executive Committee (Drs. Michael Blank and David Metzger from Penn, and Ralph DiClemente and Gina Wingood from Emory) of the SBSRN is planning for five annual meetings from 2013-17. As in the earlier SBSRN meetings, the structure of each scientific conference will consist of a mentoring day on the first day, followed by a two-day scientific meeting, and will conclude with a half-day meeting of the SBSRN Planning Committee. Scientific sessions during the two days will be interspersed with presentations by leading scientists from clinical and basic science cores. These presentations will be designed to stimulate formal discussions on how these other disciplines and core services can be more fully integrated into the research agenda of the SBSRN.
2013 - DC DCFAR Meeting, the 7th Annual Scientific Meeting of the SBSRN will be hosted by the DC CDFAR in Washington DC in 2013, and has as its theme "Optimal Combination Prevention for Populations with Health Care Disparities". The Local Planning Group for this meeting includes Drs. Maria Cecelia Zea, Paul Poppen, and Samual Simmens.
2014 - UCLA CFAR/AIDS Institute: The 8th Annual Scientific Meeting of the SBSRN will be held jointly by the UCLA CFAR and AIDS Institute. The theme of the meeting is "Optimal Combination Prevention for Populations with Health Care Disparities. The Local Planning Group for this meeting includes Drs. Gail Wyatt and Thomas Coates. This particular meeting draws on the strength of the UCLA CFAR and the UCLA AIDS Institute by combining the resources of two institutions to host the annual meeting.
2015 – Chicago DCFAR The 9th Annual Scientific Meeting of the SBSRN will be held in Chicago and hosted by the Chicago DCFAR. The theme of that meeting will be "HIV across the Lifespan". The Local Planning Group for the 2015 meeting includes Drs. Judith Levy, Robert Bailey, and Chevette Williams.
2016 – Miami CFAR: The 10th Annual Scientific Meeting of the SBSRN Miami and hosted by the Miami CFAR. The theme for that meeting will be "Integrating Biomedical Approaches to HIV prevention. The Local Planning Group for this meeting includes Drs. Lisa Metsch, Neil Schneiderman, and Derek Dykxhoorn.
2017 – UCSF CFAR/CAPS: The 11th Annual Scientific Meeting of the SBSRN 2017 meeting will be help in San Francisco and hosted jointly by the UCSF CFAR and the Center for AIDS Prevention Studies. The theme for that meeting will be "Biomedical Approaches to HIV/AIDS Prevention". The Local Planning Group for the 2017 meeting includes Drs. Steve Morin, Marguerita Lightfoot, James Kahn, and Mallory Johnson.
HIV Prevention Among Substance Abusing SMI
Michael Blank, PhD; Phyllis Solomon, PhD; Julie Tennille, MSW, LSW
Data Sources: Community Behavioral Health, Hall Mercer Community Mental Health Center, client interviews on HIV risk behaviors and drug and alcohol use
Project Dates: 2003-2008
Funding Source: NATIONAL INSTITUTE ON DRUG ABUSE RO1
Preventing AIDS Through Health (PATH) is a translation of two HIV prevention programs proven effective in the general population and among substance users. The RESPECT program was developed by CDC and is the first HIV prevention program to show one-on-one counseling can reduce at-risk sexual behavior in a multi-site demonstration. The NATIONAL INSTITUTE ON DRUG ABUSE Community-Based Outreach Model (CBOM) was designed to reduce the risk of HIV and other blood-borne infections in drug users. Both are highly structured, manualized interventions. PATH uses mental health case managers (CM's) from Hall-Mercer Mental Health Center to draw on features of both interventions depending on individual consumer risk profiles. These CM's have specialized expertise in providing services to this population. We believe that this expertise, prior relationships with these persons, and an ability to regularly reinforce the intervention will result in significantly reduced risk. There are two sets of research participants – the persons with SMI as well as case managers themselves. Informed consent will be obtained from both sets of participants. Blood testing will identify those who are HIV positive at baseline. Breathalyzer and urine testing will supplement clinical interviews and other measures to identify substance abuse co-morbidity. Using a longitudinal experimental and control group design, we will randomly assign case managers to deliver the intervention to consenting participants in their caseloads who meet inclusion criteria. Participants will be in treatment at a large CMHC in Philadelphia. Independent interviews will be conducted with case managers and consumers before the intervention, and again at 3, 6 and 12-months post intervention and focus on changes in risk behaviors, fidelity of translation of the intervention, cost and outcomes. Breathalyzer and urine tests at 12-months will supplement self-reports of use of alcohol, cocaine, marijuana, benzodiazapines, and opiates. The study has enrolled over 275 study participants to date. The research team is concluding a qualitative analysis and finishing subject interviews before beginning the analysis phase of the study.
Nursing Intervention for HIV Regimen Adherence Among SMI
Michael Blank, PhD; Aileen Rothbard, PhD,
Data Sources: Community Behavioral Health, client interviews on HIV risk behaviors and drug and alcohol use, biological outcomes
Project Dates: 2003-2008
Funding Source: NINR RO1
Involvement of advance practice nurses (APN's) has been previously shown to improve outcomes for persons with HIV/AIDS. Since case managers (CM's) are already involved with coordinating mental health, social, and other services for this population and have specialized expertise in providing those services, we believe that an integrated services model that integrates nursing and case management will result in demonstrably better HIV treatment outcomes using CD4 and viral load as indicators, and significantly reduced risk behaviors using standardized behavioral self-reports. Participants have been recruited from among those already in treatment for SMI in Philadelphia. Using a longitudinal (baseline, 6,12, and 24 months) experimental and control group design, we randomly assigned over 260 participants to the intervention or control groups. Participants were screened for active substance abuse and depression, randomized, and experimental participants received an integrated intervention tailored to their communication and comprehension levels which included memory aid devices, education regarding side effects and other treatment aspects, and active community outreach. For those who failed to adhere using the basic intervention, a treatment cascade that increases in intensity was implemented. Using 80% adherence as a target, the cascade included involvement of family and significant others in prompting participants through use of beepers, cell phones, and for those who still fell short of 80% adherence, directly observed therapy. They were randomized into experimental and control groups. Each participant was followed for 24 months. Experimental subjects received the intervention for 12 months, followed by a 12 month period during which decay of the intervention was observed. Control subjects were also observed for 24 months. Over 260 study participants have been enrolled to date. The research team is beginning report writing and analysis.
Multi-Site Rapid HIV Testing in Urban Community Mental Health Settings
Michael Blank, PhD; Trevor Hadley, PhD
Data Sources: Community Behavioral Health, client interviews on HIV risk behaviors and drug and alcohol use in Philadelphia and in Baltimore
Project Dates: 2007-2009
Funding Source: CDC under program announcement PS-07-005
This protocol outlines plans to implement a multi-site program designed to increase HIV testing and improve linkage to care for persons diagnosed with HIV in urban mental health settings serving African American communities. The project will take place in Philadelphia, PA and Baltimore, MD through a CDC collaboration with the University of Pennsylvania and the University of Maryland. In each city, the project will be implemented in three types of settings: community mental health centers (CMHCs), university-based inpatient psychiatric units, and mobile assertive community treatment (ACT) programs. In each of the settings, clients will be offered HIV testing and a brief survey to assess HIV risk behaviors, psychiatric symptoms, and HIV testing history. Abstraction of data from client medical records will provide additional information on diagnoses and recent clinical course. No subjects have been enrolled to date.
Click here to view the Nursing Intervention for HIV Regimen Adherence Among Individuals with a Serious Mental Illness Policy and Procedure Manual
Understanding Multi-system Youth and their Patterns of Services Use
Dennis Culhane, Ph.D
Project Dates: 2010-2011
Data Sources: Community Behavioral Health, claims and eligibility files, Office Supportive Housing shelter utilization, DHS files
Funding Source: Stoneleigh Foundation
This project will examine the prevalence of multi-system service involvement of youth in Philadelphia, and the dynamics of their services use. Service-engaged youth will be identified from within each of the major service systems, including truancy court, juvenile justice, foster care, homelessness and mental health. Within each system, service-engaged youth will be matched with use in other service systems. Multi-system youth will be compared to single system users, and to a matched comparison group of non-services engaged youth (non-services engaged youth will be obtained from School District of Philadelphia records). Patterns of services use will be examined, including the volume of services and sequencing of systems involvement. Early childhood and middle school antecedents to youth system involvement will also be documented. Results should provide detailed information about the size and composition of youth service users and multi-system service users, their gateways of entry into these systems, and the associated costs of their services uses. Results should suggest potential areas of interagency collaboration and programming to intervene more effectively in the lives of these youth. Future research could explore young-adult outcomes associated with the various subpopulations identified through adult records on services, education and earnings.
Homelessness among Veterans in Philadelphia: A Study Based on the Analysis of Administrative Data
Dennis Culhane, PhD
Data Sources: Community Behavioral Health, Office of Supportive Housing, Department of Corrections, U.S. Department of Veterans Affairs (VA)
Project Dates: 2010–2013
Funding Source: VA National Center on Homelessness among Veterans
The purpose of the study is to identify the degree to which veterans who are homeless in Philadelphia are using services funded by VA and other sources. The study will answer the following questions: (1) What is the frequency with which veterans in Philadelphia access services funded by the VA and other sources? (2) To what extent could veterans' services be supplanted or supplemented by access to newly expanded and newly created VA services for homeless veterans? (3) What risk and protective factors are associated with exit from homelessness, access to VA services, and other outcomes? The study will include the matching and analysis of data collected from City of Philadelphia, Office of Supportive Housing, Community Behavioral Health, and Department of Corrections; as well as the VA. The main result of this research will be improved coordination between VA and mainstream systems, improved access to VA services for veterans who are underserved by VA programs, and improved integration of homeless services to prevent homelessness and house veterans who are currently homeless. The UPenn IRB has approved this study; approval expires 4/19/2011. The VA Research and Development Service and the City of Philadelphia IRB have approved the study contingent upon specified revisions.
Healthcare Use for Children in Homeless Families
Trevor Hadley, PhD; Dennis Culhane, PhD; David Mandell, ScD
Data Sources: Community Behavioral Health, claims and eligibility files, Office of Supportive Housing files, PA health files
Project Dates: 2008-2010
Funding Source: National Institutes of Health
This study will examine 1) whether children's health service use changes before, during and after their initial homeless episode and 2) whether children who become homeless differ from other low-income housed children in their healthcare use before their first homeless episode, afterwards, and whether there are differences in the change in use around the homeless episode relative to housed children. This study aims to improve healthcare and coordination of care among children in homeless families, which will lead to improving health outcomes in this vulnerable population.
The Typology and Costs of Family Homelessness
Dennis Culhane, PhD
Data Sources: mental health treatment, child welfare, substance abuse treatment, shelter use in Massachusetts, Philadelphia, Columbus, and NYC.
Project Dates: 2007
Funding Sources: Conrad Hilton Foundation
This study aims to 1) investigate the existence of subpopulations of homeless families based on their patterns of shelter utilization and 2) examine whether subgroups of homeless families have differential utilization of public services. The research questions will be addressed by integrating data for child welfare records, Medicaid inpatient and outpatient files, and special education data from the City of Philadelphia. Our findings indicate that a substantial majority of homeless families stay in public shelters for relatively brief periods, exit, and do not return. Approximately 20 percent stay for long periods. A small but noteworthy proportion cycles in and out of shelters repeatedly. In general, families with long stays are no more likely than families with short stays to have intensive behavioral health treatment histories, to be disabled, or to be unemployed. Families with repeat stays have the highest rates of intensive behavioral health treatment, placement of children in foster care, disability, and unemployment. The results suggest that policy and program factors, rather than family characteristics, are responsible for long shelter stays. An alternative conceptual framework for providing emergency assistance to homeless families is discussed.
Kids Integrated Data System (KIDS)
Dennis Culhane, PhD; Trevor Hadley, PhD and John Fantuzzo, PhD
Data Sources: School District of Philadelphia, Behavioral Health Services, Office of Supportive Housing, Department of Human Services, Department of Public Health
Project Dates: 1998-2008
Funding Sources: William Penn Foundation
Abstract: KIDS was a partnership between the City of Philadelphia and the University of Pennsylvania to create an integrated database of children's health, education and social services for purposes of research. This on-going project involves the construction annually of data on children's mental health obtained from the Philadelphia Department of Mental Health. As of 2009, these activities are continuing under the Policy Analysis Center.
Policy Analysis Center
Dennis Culhane, PhD; John Fantuzzo, PhD
Data Sources: City of Philadelphia, School District of Philadelphia
Project Dates: 2009-2012
Funding Sources: William Penn Foundation
This project continues the work of KIDS. Managed by the City's Office of Health and Opportunity, the PAC is designed to maximize the use of scientifically valid research with integrated administrative data to improve health, education and social services for Philadelphia residents.
Intelligence for Social Policy (ISP)
Dennis Culhane, PhD and John Fantuzzo, PhD
Data Sources: n/a
Project Dates: 2009-2012
Funding Sources: John D. and Catherine T. MacArthur Foundation
This initiative aims to improve the quality of education, health and human service agencies' policies and practices through the use of integrated data systems. ISP promotes a professional network, establishing guidelines for practice, and demonstrating research and analytic capacities that integrated data systems enable.
Philadelphia Homeless Diversion Project
Dennis Culhane, PhD and Steve Poulin, PhD
Data Sources: Office of Supportive Housing
Project Dates: 2007-2008
Funding Sources: City of Philadelphia
Abstract: The Homeless Diversion Project was originally an evaluation of a rapid re-housing approach to family homelessness sponsored by the Philadelphia Office of Supportive Housing. The Project was expanded to include the study of families who applied for shelter but made other housing arrangements. The goals of this project were: 1) assess the benefits and cost efficiency of providing short shelter stays followed by subsidized housing and move-in assistance as an alternative to the provision of shelter only to homeless families, and 2) explore the circumstances of homeless families whose head of household applied for shelter but was able to make his or her own living arrangements (MOA). CMHPSR staff identified the factors associated with MOA families requesting shelter again, and compared the stability and well-being of the experimental and control group high risk families. Families identified as being at high risk of repeated homelessness who have been in shelter for 45 days or more received housing assistance from a contracted non-profit organization that includes placement into an affordable and appropriate subsidized housing unit soon after shelter admission. Results: Among the 49 homeless families who were immediately placed into subsidized housing with case management services, the heads of household reported that their monthly incomes had increased by 36% over the one-year period they were interviewed.
Healthcare Use for Children in Homeless Families
Trevor Hadley, PhD; Dennis Culhane, PhD; David Mandell, ScD; Data Sources: Community Behavioral Health, claims and eligibility files, Office of Supportive Housing files, PA health files
Project Dates: 2008-2010
Funding Source: National Institutes of Health
This study will examine 1) whether children's health service use changes before, during and after their initial homeless episode and 2) whether children who become homeless differ from other low-income housed children in their healthcare use before their first homeless episode, afterwards, and whether there are differences in the change in use around the homeless episode relative to housed children. This study aims to improve healthcare and coordination of care among children in homeless families, which will lead to improving health outcomes in this vulnerable population.
Fostering Community Integration: A Cross-Disability Study of Community Residential Services
Yin-Ling Irene Wong, PhD; Trevor Hadley, PhD; Siu-Shing Chan; PhD
Data Sources: Addresses and capacity data on community residential services for people with psychiatric disabilities and people with intellectual/developmental disabilities funded through the Philadelphia Department of Public Welfare
Project Dates: 2009-2010
Funding Source: National Institute on Disability and Rehabilitation Research, U.S. Department of Education
Supporting people with disabilities in integrated housing is a major goal of rehabilitation policy in the United States; therefore, it is important to identify factors that shape community residential services (CRS). This project uses a comparative case study design involving both quantitative and qualitative research approaches. Geographic information systems methodology is applied to assess various facets of the spatial contexts of people with psychiatric disabilities (PD) and intellectual or developmental disabilities ID/DD receiving CRS in eight counties from four states examining the extent to which the two populations are living in integrated housing, as well as the conditions of their neighborhoods. Semi-structured phone interviews with 12 representatives from 3 stakeholder groups in 2 states are conducted to generate an in-depth understanding of factors that contribute to the spatial patterns of CRS for people with PD and ID/DD. The stakeholder groups include consumer advocacy groups, service providers, and program planners/policy makers. Additionally, the project engages in a participatory action research approach by collaborating with key stakeholders at every stage of the research process. This research facilitates capacity building and improves operation of community-based service delivery systems. See 2009-2010 publications: Wong, Matejkowski & Lee, (2010).
Comprehensive Evaluation of Philadelphia County's School-Based Mental Health Programs
Trevor Hadley, PhD and Christina Kang, PhD
Data Sources: Community Behavioral Health claims and School District data
Project Dates: 2009-2011
Funding Source: Internal DBH evaluation
This study examines the impact of the Philadelphia County's school-based mental health programs including School Therapeutic Support Services (School TSS) and School-Based Behavioral Health (SBBH)/Nurture on children's school functioning. Outcome indicators are changes over time in children's number of monthly absent days, number of monthly suspension days, and annual grade promotion. The study sample includes all children who entered one of the school-based mental health programs listed above during the academic year 2006-2007 and have school records available. The sample includes 522 children with average age of 10 in 227 different schools of Philadelphia County. A combined dataset of City of Philadelphia Community Behavioral Health's Medicaid Claim data and School District of Philadelphia's student academic and behavioral data are used to perform the evaluation.
Mental Illness, Substance Abuse, and Jail Reentry
Jeffrey Draine, PhD; Trevor Hadley, PhD; Steve Metraux, PhD and Amy Blank-Wilson, PhD
Data Sources: MA and Community Behavioral Health data matched with prison entry and exit data, Interviews with system stakeholders, focus groups with providers and consumers
Project Dates: 2008-2011
Funding Source: Philadelphia Department of Behavioral Health and University of Pennsylvania Leonard Davis Institute
We are analyzing the patterns of service use prior to jail entry, pathways through jail, and service use after jail release for individuals with behavioral health disorders entering and leaving Philadelphia jails Data collection and analysis continues. This initially will result in reports for Dr. Evans, and two published papers in progress on the trips into, through, and after jail for people with mental illness. The paper for length of stay in the jail has already been published in Psychiatric Services (see publication listing). The analysis of services after jail release and the extent to which service use explains whether or not people return to jail is now under way and will be complete within the year.
Kids Integrated Data System (KIDS)
Dennis Culhane, PhD and Trevor Hadley, PhD
Data Sources: School District of Philadelphia, Behavioral Health Services, Office of Supportive Housing, Department of Human Services, Department of Public Health
Project Dates: 1998-2008
Funding Sources: William Penn Foundation
KIDS was a partnership between the City of Philadelphia and the University of Pennsylvania to create an integrated database of children's health, education and social services for purposes of research. This on-going project involves the construction annually of data on children's mental health obtained from the Philadelphia Department of Mental Health. As of 2009, these activities are continuing under the Intelligence for Social Policy (ISP) initiative. Funded by the Catherine T. and John D. MacArthur Foundation through a three-year grant to University of Pennsylvania Professors Dennis Culhane, School of Social Policy and Practice, and John Fantuzzo, Graduate School of Education this initiative aims to improve the quality of education, health and human service agencies' policies and practices through the use of integrated data systems.
School-Based Behavioral Health Program: Behavioral Outcome Assessment
David Mandell, ScD, Trevor Hadley, PhD, Christina Kang, PhD
Data Sources: Medicaid claims combined with educational records
Project Dates: 2009-2011
Funding Sources: Philadelphia Department of Behavioral Health
This study examined the effectiveness of School-Based Behavioral Health Program (SBBH) through comparing Achenbach System of Empirically Based Assessment (ASEBA) outcomes at baseline, 120-day, 240-day, and 360-day assessments. Specific research questions included: (1) Is there any significant changes in children's competence, adaptive functioning, and problems over one-year time period? (2) Is there any significant difference in the children's competence, adaptive functioning and problems by agency? (3) Is the change over time in the ASEBA subscales significantly different by agency? Both parent-reported and teacher-reported outcomes were examined in this study. The parent-report analysis included 1,136 children-unique counts and 3,073 assessments and the teacher-report analysis included 1,104 children-unique counts and 2,982 assessments. Results: The school-based BHRS programs had significant positive effect over time decreasing children's symptomatology. However, the results did not support clinically significant change. The effect of the school-based BRHS programs was significantly different by agency. Some agencies showed significantly greater improvement than others. ASEBA externalizing problem subscale showed sensitivity in measuring change in the outcome. However, other subscales may be less sensitive to the change. Teachers and parents showed consistency in observing children's externalizing problem, while they showed great difference in their perception on children's internalizing problems. The different perceptions on children's internalizing problems between teachers and parents suggest the importance of communication between teachers and parents in the effort of meeting children's needs. The program should strengthen family and teacher engagement component. A more structured program is important for the evidence-based practice. More structured programs will lead to better evaluation of the effectiveness of the program by indicating which component of the program leads to better outcome. Our examination of the change in children's symptomatology was limited to one year due to the data availability. We may see different results with a longer period of observation. A higher rate of data submission is important to find more conclusive effect of the program.
Medicaid Service Utilization for persons discharged from county prison system
Steve Metraux, PhD; Jeffrey Draine, PhD; Amy Blank Wilson, PhD; Trevor Hadley, PhD
Data Sources: Department of Behavioral Health
Project Dates: 2010-2010
Funding Sources: Department of Behavioral Health Evaluation Center
This analysis investigated whether persons with serious mental illnesses have longer jail detentions than other detainees and whether they are released by different legal mechanisms. Jail records and mental health service records from a Medicaid database were matched for all admissions to the Philadelphia jail system in 2003. Survival analysis techniques were used to compare length of jail stays of persons with and without serious mental illnesses (N=24,290). Serious mental illness was defined as a diagnosis either in the schizophrenia spectrum (DSM-IV code 295.XX) or of a major affective disorder (DSMIV code 296.XX) recorded in Medicaid records (2001–2003). Mechanisms of release were also examined for those with release dates before September 1, 2005 (N=20,573) Results: Just over 50% of the 1,457 persons with serious mental illnesses were released from jail within 30 days of incarceration, compared with 56% of the other detainees. Mental illness status was not found to be a significant predictor of longer detentions. Forty-nine percent of those with serious mental illnesses were released from jails through unpredictable release mechanisms, such as bail, release from court, or withdrawal of a bench warrant, whereas only 19% were released through mechanisms that had release dates that allowed adequate time for discharge planning. The findings suggest that reentry programs and other jail-based interventions for persons with mental illnesses should ensure that they have the capacity to rapidly identify and serve clients with shorter and more unpredictable stays or risk not being responsive to the needs of a substantial proportion of this population
Understanding the Delay in the Diagnosis of Autism
David Mandell, ScD
Data Sources: primary data
Project Dates: 2005– 2010
Funding Sources: National Institute of Mental Health
The purpose of this Mentored Research Scientist Career Development (K01) award was to develop a program of research related to understanding the pathways and processes by which children with autism are screened, diagnosed and enter treatment. As part of the education plan, the PI received training to: 1) Increase his understanding of the presentation, diagnosis of and treatments for autism; 2) Increase his knowledge of different systems through which services for children with autism are provided; 3) Learn about the epistemologies that informs professionals' and families' understanding of autism by promoting interaction with families of children with autism and the professionals who come into contact with them; 4) Improve his knowledge of related fields such as neuropsychology, decision-making and communication; 5) Gain additional research skills to collect and analyze primary data about complex, multilayered issues; and 6) Acquire the skills associated with the development of interventions. A three-phase study that builds upon a federally funded prevalence study was conducted as part of this career development award. In Phase I, children with autism were identified using medical and school records. Information from chart reviews of sources were used to identify factors associated with the age at which children with autism are diagnosed. Phase II sampled families based on factors found in Phase I to be associated with age of diagnosis. Through semi-structured interviews, these families were asked to describe their experiences related to their children's autism, what precipitated their concerns, and experiences related to getting screened, diagnosed and treated. Models and methods developed in Phases I and II informed data collection efforts in Phase III. Phase III enrolled families whose children had recently screened positive for autism. Both quantitative and qualitative data were collected from families who were interviewed near the time their child was screened. Parents of children who were subsequently diagnosed with autism were interviewed again at that time, and also 12 months later. Data was gathered on stress, sources of support, and their decisions about whether and how to engage in treatment. In addition to acting as a pilot for the methods and instruments used in Phase III, Phases I and II helped the PI develop skills associated with mixed methods studies that will be applied to prospective data collection, analysis and interpretation. It is anticipated that as a result of this research, interventions will be developed that decrease the age at which children with autism receive the diagnosis and enter treatment. In addition, the results from this study may inform our understanding of factors affecting the early and appropriate diagnosis of other psychiatric and developmental disorders of childhood, leading to the development of broader interventions to expedite appropriate diagnosis.
Interstate variation in healthcare utilization among children with ASD
David Mandell, ScD
Data Sources: Medicaid claims data from 2001-2007
Project Dates: 2007 – 2012
Funding Sources: National Institute of Mental Health
The purpose of this R01 is to conduct a large national study that will comprehensively identify the impact of state level autism-related policies on the publicly funded healthcare utilization of children with autism spectrum disorders (ASD). The three primary aims of the study are to 1) conduct an intensive examination of state policies and practices that may affect Medicaid-reimbursed healthcare delivery to children with ASD; 2) provide accurate national and state-level estimates of publicly-funded healthcare utilization among children with ASD; and 3) examine the relative contribution of demographic, clinical and system-of-care characteristics on the types, intensity and patterns of related service use. To accomplish these aims, we will review and code all relevant state-level policy documents to define the publicly funded healthcare service delivery system for ASD in each state. We will supplement this census through interviews with state administrators responsible for ASD-related health services. This most recent year of available Medicaid claims will be used to measure service utilization and associated expenditures at the national and state levels. We will then examine the independent associations of state policies, and school district, family and child characteristics with service utilization. These findings will provide critical information to states as they develop appropriate standards of care and related policies for the growing number of children diagnosed with ASD, and will potentially lead to policy models that improve care. This study will set the stage for future studies in which service utilization data from other systems and primary data about families' experiences and outcomes are linked to data on healthcare. The study also will provide a baseline against which to measure the effects of future system-level interventions. Finally, the results will provide evidence for a conceptual framework for understanding how states address the needs of children with chronic disabilities in which the best course of treatment and expected outcomes are uncertain.
A Randomized Trial of the STAR Program for Children with Autism Spectrum Disorders
David Mandell, ScD
Data Sources: primary data
Project Dates: 2008-2010
Funding Sources: National Institute of Mental Health
This study capitalizes on the impending implementation of STAR (Strategies for Teaching Based on Autism Research) in the School District of Philadelphia and seeks support to conduct a randomized controlled field trial of this classroom-based program. The primary aims are to examine the effects of STAR versus the comparison condition on academic progress and impairments associated with ASD. We will assess changes, over the course of an academic year, in: 1. School readiness, with a focus on pre-academic skills; 2. Communication, including use of expressive and receptive language; 3. Socialization and social skills; and 4. Adaptive and challenging behaviors. The secondary aims are to examine the potentially moderating role between STAR and these outcomes of: 1. Children's symptoms and chronological and developmental age at baseline; 2. Teacher effects, specifically fidelity of program implementation and training and experience; 3. Other interventions received prior to and concurrent with the study period; and 4. Family characteristics. The Philadelphia School District plans to use STAR for the approximately 330 children in 42 kindergarten- through-2nd grade autism support classrooms starting in September 2008. If this proposal is funded, the district will randomize teachers and aides in half of these classrooms to STAR training and delay training the other half until 2009. Teachers in the latter group will receive training of equal intensity in Structured Teaching, the district's current standard of care. Measures will be taken at the beginning, middle and end of the academic year. Child measures will address academic progress, communication, socialization and behavior, clinical presentation and use of other interventions. Teacher measures will include knowledge, experience, and job-related stress. We will assess program fidelity through independent observations. Findings from the proposed study would provide timely and critical evidence regarding the implementation and effectiveness of one promising practice, with direct relevance to translation of findings into practice and policy.
The Prevalence of Autism among a Psychiatric Inpatient Population
David Mandell, ScD
Data Sources: primary data combined with chart review
Project Dates: 2008-2009
Funding Sources: Pennsylvania Department of Public Welfare, Department of Defense
This study estimated the ASD prevalence in a psychiatric hospital and evaluated the Social Responsiveness Scale (SRS) combined with other information for differential diagnosis. Chart review, SRS and clinical interviews were collected for 141 patients at one hospital. Diagnosis was determined at case conference. Receiver operating characteristic (ROC) curves were used to evaluate the SRS as a screening instrument. Chi-squared Automatic Interaction Detector (CHAID) analysis estimated the role of other variables, in combination with the SRS, in separating cases and non-cases. Ten percent of the sample had ASD. More than other patients, their onset was prior to 12 years of age, they had gait problems and intellectual disability, and were less likely to have a history of criminal involvement or substance abuse. Sensitivity (0.86) and specificity (0.60) of the SRS were maximized at a score of 84. Adding age of onset <12 years and cigarette use among those with SRS <80 increased sensitivity to 1.00 without lowering specificity. Adding a history substance abuse among those with SRS >80 increased specificity to 0.90 but dropped sensitivity to 0.79. Undiagnosed ASD may be common in psychiatric hospitals. The SRS, combined with other information, may discriminate well between ASD and other disorders.
Pennsylvania Autism Needs Assessment
David Mandell, ScD
Data Sources: Primary survey data combined with Medicaid claims and education records
Project Dates: 2008 – 2011
Funding Sources: Pennsylvania Department of Public Welfare, Bureau of Autism Services
The Pennsylvania autism needs assessment was conduct as part of the activities of the Autism Services, Education, Resources and Training Center. The needs assessment comprised a survey of more than 3,500 individuals with autism and their caregivers to learn about their service needs and experiences. These data will be used to guide policy decisions in Pennsylvania and they relate to the implementation of practices to support individuals with autism.
Patient Safety in Inpatient Psychiatry
Steven Marcus, PhD
Data Sources: A random sample of 11,000 medical records from 38 inpatient psychiatric units of acute care hospitals in Pennsylvania.
Project Dates: 2010-2014
Funding Sources: National Institutes of Health
The project seeks to assess the incidence, nature and preventability of patient safety events via a record review of 11,000 patient medical charts in a random sample of 38 inpatient psychiatric units of general hospitals in Pennsylvania.
Adherence and Empowerment: Service Participation and Meaningful Outcomes
Patrick Corrigan, PhD and Steve Marcus, PhD
Data Sources: Multiple projects that include primary data collection and analysis of large administrative data sources
Dates: 2009-2014
Funding Sources: National Institutes of Mental Health.
The research seeks to better understand strategies that enhance empowerment and adherence, which, in turn, influence participation in quality services and achievement of personally meaningful goals for persons with SMI.
Efficacy and sustainability of the STAR program
David Mandell, ScD
Data Sources: primary data
Project Dates: 2008-2012
Funding Sources: Department of Education
This project aims to examine the long term effects of STAR, an autism teaching intervention, versus a comparison teaching condition on academic progress and impairments associated with autism.
Detection and Care for Depression in the Peripartum
James Coyne, PhD
Data Sources: Longitudinal surveys of women at two obstetrics clinics
Project Dates: 2008-2013
Funding Sources: National Institutes of Mental Health
The overarching goal is to identify influences on access and barriers to care for MDD in pregnancy and postpartum.
Evaluating Pay for Performance and its Design: Evidence from Nursing Homes
Rachel Werner, MD, PhD
Data Sources: Medicare Nursing Home Minimum Database
Project Dates: 2010-2013
Funding Sources: National Institute of Aging
The overall objective of this study is to assess the relationship between pay for performance and the delivery of high-quality care in the setting of nursing homes.
Evaluation of Delaware's Trauma-Informed-Care System Initiative (T-IC)
Cynthia Zubritsky, PhD and Aileen Rothbard, ScD
Data Sources: Delaware Division of Substance Abuse and Mental Health Administrative Database Project Dates: 2010-2015
Funding Sources: DEL subcontract, SAMHSA
The goal of the Delaware Trauma-Informed-Care System Initiative (T-IC), funded through a five year grant from SAMHSA, is to develop a trauma-informed mental health and co-occurring care system through: 1) preparing outpatient mental health and co-occurring system providers and peer specialists to build a system of care based on a specified set of principles and values that integrate trauma experiences into the treatment program; 2) provide universal trauma screening and assessment to everyone in the system; and 3) train peer specialists to provide trauma-informed recovery services. The evaluation activities involve the analysis of the trauma assessment screen and assessment tool with respect to demographics and source of trauma, collection and analysis of national data elements (NOMS) on clinic populations, system level descriptions and monitoring of changes in attitudes and knowledge regarding trauma of clinicians and workforce in general, assessment of role of peer specialists in enhancing the quality of treatment for those with trauma issues and evaluation of IMR recovery groups co-led by peer specialists.
Evaluation of Delaware's Co-occurring State Incentive Grant (COSIG)
Cynthia Zubritsky, PhD and Aileen Rothbard, ScD
Data Sources: Delaware Division of Substance Abuse and Mental Health Administrative Database
Project Dates: 2010-2015
Funding Sources: DEL subcontract and SAMHSA
The Substance Abuse and Mental Health Service Administration (SAMHSA) awarded a Co-occurring State Incentive Grant (COSIG) to the State of Delaware, Delaware Department of Health and Social Services (DHSS), in 2007. The goal of the intervention is to increase state capacity to provide integrated treatment for MH and SA through a practice-change intervention. System wide training as well as agency consultations using "live" consumer interviews, role playing &/or case presentations. An additional intervention has been the use of a strategy developed by the Network for the Improvement of Addiction Treatment (NIATx) to provide the Change Leader Academy to designated staff from participating agencies. The trainees or Change Leaders are provided TA aimed at changing practices within their agencies. Each Change Leader developed a team and participated in conference calls as well as day-long trainings. The evaluation will assess the extent to which the state changed its organizational infrastructure to improve COD treatment, the degree to which providers increased their case finding of individuals with COD using screening and assessment tools, the amount of integration that occurred as a result of training and consultation, the perception of staff and consumers with regard to the changes.
Evaluation of Delaware's Strategic Initiative to enhance community integration of individuals with serious mental disorders
Cynthia Zubritsky, PhD and Aileen Rothbard, ScD
Data Sources: Delaware Division of Substance Abuse and Mental Health Administrative Database and Delaware Medicaid Database
Project Dates: 2011-2016
Funding Sources: DEL subcontract – Department of Justice
The United States Department of Justice (DOJ), under the Olmstead Act, has required that the State of Delaware provide the most integrated setting appropriate to meet the needs of persons with SMI with respect to community integration, planning, and services to support individuals at risk of institutionalization. UPENN investigators were awarded a contract to evaluate the implementation of new community initiatives and the extent to which these initiatives produce the stated benchmarks of appropriate access and utilization of community services with a reduction in crisis care, arrests/incarceration/shelter utilization rates and increased employment rates. The analysis will involve both qualitative and quantitative assessments of access and utilization. Fidelity to various treatment programs will also be monitored.
Services in Supported Housing (SSH) Program National Outcome Evaluation.
Aileen Rothbard, ScD; Dennis Culhane, PhD; Irene Wong, PhD; Elizabeth Noll, MA and Trevor Hadley, PhD
Data Sources: Program survey data, NOMS client level data, administrative data from study sites
Project Dates: 2010-2011
Funding Sources: SAMHSA, RTOP Proposal 280-11-0268
The above faculty from the University of Pennsylvania's Center for Mental Health Policy and Services Research (CMHPSR) were involved in a SAMHSA funded study with the Human Services Research Institute (HSRI) to design the SSH Program National Outcome Evaluation. During 2010 we developed an evaluation plan that examined grantees' fidelity to the PSH model, and the comparative effectiveness of different evidence-based practices for people who are or have been homeless. The analysis we are developing examines the cost, neighborhood context and housing characteristics, as well as consumer characteristics related to maintaining housing. The contract has been revised and rolled up into a national evaluation of all housing programs funded by SAMHSA.
Evaluation of Programs to Provide Services to Persons Who Are Homeless with Mental and/or Substance Use Disorders.
Aileen Rothbard, ScD; Dennis Culhane, PhD; Irene Wong, PhD; Elizabeth Noll, MA and Trevor Hadley, PhD
Data Sources: NOMs client data, GPRA client data, program survey data, administrative data from study sites
Project Dates: 2011-2016
Funding Sources: RFTOP No. 280-11-0368, SAMHSA
The above faculty in the Center for Mental Health Policy and Services Research (CMHPSR) are partners with RTI International in response to RFTOP No. 280-11-0368, "Evaluation of Programs to Provide Services to Persons Who Are Homeless with Mental and/or Substance Use Disorders." The programs to be evaluated are the Programs for Assistance in Transition from Homelessness (PATH), the Services in Supportive Housing (SSH) program, the Grants for the Benefit of Homeless Individuals (GBHI) program, and the new Cooperative Agreements to Benefit Homeless Individuals (CABHI) program. One of SAMHSA's overall objectives for the evaluation is to enable comparisons across the GBHI, SSH, CABHI, and PATH programs while addressing the salient characteristics of the individual programs. The major focus of these four homeless programs is on recovery support through services to individuals living in these housing sites.
Cost of Care for Co-Occurring individuals following an HIV Prevention Program and Nursing Intervention for HIV Regimen Adherence among SMI (PATH and PATH+)
Aileen Rothbard, ScD, Elizabeth Noll, MA; Sumedha Rasu, PhD Michael Blank, PhD
Data Sources: Philadelphia Department of Behavioral Health
Project Dates: 2010-2011
Funding Sources: National Institute on Drug Abuse and the National Institute on Nursing Research
This study uses secondary data from the Philadelphia Department of Behavioral Health to construct cost measures on two cohorts of individuals recruited from community based programs. The projects involved two separate randomized trials for: 1) HIV prevention (PATH); and 2) HIV adherence (PATH+). The studies were implemented simultaneously between 2004 and 2009 and were funded by NIH. The PATH study (Preventing AIDS Through Health) was designed to reduce the risk of contracting HIV and other blood-borne infections in co-occurring individuals. Highly structured, manualized interventions were used in the PATH study. for PATH+, the objective was to increase adherence through an integrated intervention by Advanced Practice Nurses, tailored to an HIV/SMI population. Both projects involved a longitudinal experimental and control group design. In PATH, subjects were randomly assigned case managers to deliver the intervention to consenting participants in their caseloads who met inclusion criteria. Independent interviews were conducted with case managers and consumers before the intervention, and again at 3, 6 and 12-months post intervention and focus on changes in risk behaviors, fidelity of translation of the intervention, cost and outcomes. In the PATH+ study, individuals in the experimental group received services related to adherence that included memory aid devices, education regarding side effects and other treatment aspects, and active community outreach. Data was collected at baseline, 6,12, and 24 months For those who failed to adhere using the basic intervention, a treatment cascade that increased intensity was implemented. Participants were recruited from among those already in treatment for SMI in one of four large urban CMHC's in Philadelphia. A total of 600 subjects were recruited, 300 in each project. IRB approval for continuation will be requested.
Implementing an E-Prescribing System in Outpatient Mental Health Programs
Aileen Rothbard, ScD; Trevor Hadley, PhD; Cynthia Zubritsky, PhD and Elizabeth Noll, MA
Data Sources: Electronic prescribing health records from clinic sites
Project Dates: 2004-2007
Funding Sources: Pennsylvania Department of Health
This study, funded by the State of Pennsylvania examined the implementation and evaluation of an electronic prescription ordering system and feedback report in three community-based mental health outpatient agencies and the usefulness of the system in improving psychiatrists' prescribing behavior. Using the e-prescribing system as a data collection tool, feedback on evidence based prescribing practices for patients diagnosed with schizophrenia spectrum disorder or major affective disorder was provided to agency directors and prescribers via a monthly report. Our findings showed a small impact of the feedback intervention in reducing questionable prescribing patterns especially notable in prescribing for a diagnosis of major depressive disorder. Some of this may be attributed to our use of a cross-sectional design with non-equivalent comparison groups. On the other hand, the majority of psychiatrists participating in the focus groups felt that the e-prescribing system had a positive impact on their prescribing practices because it saved time, made it easier for them to read previous medications than hand-written chart notes, and encouraged them to review and update their pharmacologic knowledge. Many felt that communication with their patients increased as a result of the psycho-educational modules of the e-prescribing tool that provided printable medication brochures that prescribers considered more informative than pharmaceutical handouts. Our findings suggest that e-prescribing tools can be installed and can provide useful information for monitoring and clinical decision making in public mental health systems. Given the availability of administrative claims data and electronic prescribing technology, interventions using feedback mechanisms have considerable potential for clinical support.
Costs of Implementing a Computerized Prescription Systems in pubic mental health agencies to Improve QOC and reduce Disparities
Aileen Rothbard, ScD; Eri Kuno, PhD; Trevor Hadley, PhD
Data Sources: Administrative cost data from clinics and Pennsylvania Department of Health grant fund data
Project Dates: 2004-2007
Funding Source: Pennsylvania Department of Health
Four not-for-profit specialty mental health agencies in an urban setting comprised the study population. The number of psychiatrists working at the agency ranged from 5 to 10 FTE. The prescribing system employed in the project was a web-based system that charged monthly fees per prescribing and non-prescribing user. The costs of upgrading the computer system varied from $1,460 to $6,900, depending on the size of the agency and the state of their information infrastructure. The information system staff devoted approximately 116 hours ($3,248) to implement the prescribing system. The human resource costs for training was around $4,500 per agency, including psychiatrists' time ($1,500 to $2,700). The fees for training and support for system activation was divided by 4 agencies, costing $9,000 each. In addition, we estimated that the pre-implementation decision making process for each agency cost between $2,600 to $3,600. The actual utilization of the system was a gradual process. Full implementation was accomplished in 6 to 9 months following the initial training.. Delays in implementation were due to insufficient clinician buy-in, inadequate workflow assessment and need to upgrade information systems The total initial costs ranged from $20,572 to $27,549 per agency. Annual ongoing costs were expected to range from $9,877 (5 FTE agency) to $14,677 (10 FTE agency). On a per psychiatrist based expenditure, initial costs per prescribing physician averaged $2,385 ($1,900-3,133) and ongoing cost per physician averaged $1,100 ($1,000-1,162). Compensation of psychiatrists time was a major incentive for public sector agencies to implement the computerized prescription system. The cost analysis shows that the technology expenditure itself is not prohibiting for initial implementation as well as ongoing support. Once the computerized prescription writing becomes routine practice, the system can be expanded to include other clinical information that can be linked to client outcomes. Providing initial financial support to implement a well-designed computerized prescription system is a valuable policy option, along with technical assistance in implementation, considering long-range benefits of the technology for monitoring and improving quality of care for public sector clients.
A Methodological Approach to Estimating Cost Savings in Adherence Intervention Studies for Individuals with HIV
Evan Wu, PhD; Aileen Rothbard, ScD and Michael Blank, PhD
Data Sources: Medicaid claims data
Project Dates: 2004
Funding Sources: National Institute on Drug Abuse
Determining the economic feasibility of adherence interventions among individuals with HIV and serious mental illness is important for program planners who must make resource allocation decisions. The goal of this study was to provide a methodology to estimate the cost savings associated with these interventions. This analysis used a unique methodology to estimate the cost savings associated with a medication adherence intervention for individuals with HIV and serious mental illness (SMI) using cost summary data stratified by CD4 count and developed by investigators at the University of Alabama at Birmingham (UAB) HIV clinic. We applied their cost estimates to a study population from a University of Pennsylvania (UPENN) HIV adherence intervention clinical trial and created cost savings measures by adjusting the UAB population estimates to the HIV/SMI comorbid population in the UPENN sample. The overall intervention cost savings using this method were $3,735 per participant per year in the intervention group. Given the difficulties encountered by researchers in obtaining and constructing healthcare costs, the method presented in this paper allows researchers to analyze the cost differences of their intervention compared with treatment as usual groups using their own CD4 population data combined with UAB cost estimates.
Evaluating the Effectiveness of a High End Users Program for Persons with Psychiatric Disorders
Aileen Rothbard, ScD; Cynthia Zubritsky, PhD; Sumedha Chhatre, PhD
Data Sources: Delaware State Office of Substance Abuse and Mental Health administrative data
Project Dates: 2007
Funding Sources: Delaware State
The purpose of this study was to evaluate whether an intensive case management program for high users (HEU) of inpatient care was an effective means of reducing psychiatric inpatient utilization, when compared to usual care. Those individuals enrolled in the HEU program and those patients whose psychiatric inpatient histories matched the HEU criteria were selected for comparison. A pre- post study design was employed to evaluate the changes in inpatient days following participation in the program. Because this was not a randomized trial, statistical tools were employed to control for any differences between the groups. The findings support other research on high end users employing a pre post design that show a decline in inpatient days following a period of high inpatient utilization. However, the results are also consistent with several randomized trials that find that the HEU intervention program was not more effective in reducing inpatient use than treatment as usual. In fact, the members of the high end user group in this current study were more likely to be re-hospitalized than the comparison group. The fact that the vast majority of individuals in the intervention group had multiple versus one long hospital stay during the pre-period suggests that these individuals may not have been stabilized at the time of their enrollment in the study. Policy makers must evaluate the effectiveness of these programs in the future given these results.
Simulation Model for Residential Bed Planning for Persons with Mental Disorders
Aileen Rothbard, ScD; Naoru Koizumi, PhD; Cynthia Zubritsky, PhD; Eri Kuno, PhD
Data Sources: Delaware State Office of Substance Abuse and Mental Health administrative data
Project Dates: 2006-2011
Funding Sources: National Institute of Mental Health
This is the second NIMH funded grant (PI, Kuno; co-PI Rothbard) to explore model development for planning residential service systems. This project refined the original model that was based on the Philadelphia mental health system. Model input parameters were originally derived from empirical data on the public sector sub-acute inpatient and residential service utilization records. In the current project, we have improved on the client flow decision support tool by employing a new approach based on client need. A functional status classification scale has been applied to assign appropriate "levels of care" among clients in need of hospital and residential services. Transition patterns showing changes in client functioning between levels of care are incorporated into the model, using a local expert panel to estimate change rates; 2) The effect of high intensity outpatient services such as Assertive Community Treatment (ACT) and Intensive Case Management (ICM) programs is being incorporated into the model with the objective to reduce demand for staffed residential services. 3) Finally, we added a cost component to the planning model in order to project what monetary funds are needed. Secondary data from the Philadelphia mental health system is being used and this is being replicated in the Delaware state MH system.
Mental Health Resource Capacity in Pennsylvania
Aileen Rothbard, ScD; Elizabeth Noll, MA; Trevor Hadley, PhD
Data Sources: Pennsylvania state hospital data (PCIS), Pennsylvania Cost Containment Council data (PHC4), Medicaid expenditure data, jail survey data and census data
Project Dates: 2007-2009
Funded Pennsylvania Department of Public Welfare
As a result of the downsizing and closure of state psychiatric hospitals, there are concerns that adequate resources exist to ensure the safe transition and recovery of individuals in the community. Additionally, questions are raised as to whether there are sufficient resources available for individuals who were not formerly in institutional settings but may require community based care. This study examined psychiatric treatment capacity in Pennsylvania hospital over a 16 year period between 1990 and 2006. The trends in the number of beds, length of stay, occupancy rates, emergency room admissions, and the extent of geographic variation in psychiatric resources across Pennsylvania were analyzed. Factors related to the variation of psychiatric beds were identified so that policy makers can better understand the adequacy of psychiatric resources in the state. This study involved a longitudinal descriptive analysis of the number of state hospital, acute and sub-acute community hospital beds, patient discharges, and per capita mental health and residential expenditures from public sources such as Medicaid and state block grant funds by region and county. Data sources included Pennsylvania state hospital data (PCIS), Pennsylvania Cost Containment Council data (PHC4), Medicaid expenditure data, jail survey data and census data. Patient discharges from non-state hospital beds for psychiatric diagnoses, as well as substance abuse diagnoses, by "all payers" were included. Mapping techniques were used to identify clusters of high and low utilization. Correlation analysis was used to identify potentially significant factors associated with bed capacity and utilization.
Our findings showed a 29% decline in total psychiatric beds, however, despite the 15% decrease in non-state psychiatric beds, discharges increased by 32%, suggesting that the reduction in community beds did not prevent people from being hospitalized. This was accomplished, in part, by a 33% decrease in average length of stay (15 days to 10 days) which allowed greater turnover. During this period, hospitalizations for substance abuse diagnoses decreased 68%, while a doubling of hospitalizations for affective diagnoses occurred. With regard to rehospitalization rates, readmission to non-state psychiatric beds rose slightly from 1.3 per person in 1990 to 1.4 in 2006 and admissions to a psychiatric bed through the Emergency Room increased from 42% to 48%. Payer status remained fairly constant with the percent of Medicaid discharges in 2006 at 28%, Medicare Discharges at 21%, Commercial/Private Insurance Discharges was 43%. The average occupancy rate for non-state psychiatric hospital beds in 2006 was 62%. The trend showing a decline in inpatient psychiatric beds and length of stay and an increase in discharges in Pennsylvania is comparable to the US trend. Despite the bed declines, there is no evidence to support a "revolving door" syndrome as annual episodes per person have increased only slightly over the 16 years and the time to rehospitalization is similar over the entire period as well.
Cost Analysis of Persons with SMI and HIV/AIDS in 2003
Aileen Rothbard, ScD; Sungeun Lee, PhD; Michael Blank, PhD
Data Sources: Medicaid claims data
Project Dates: 2008
Funding Sources: National Institute on Drug Abuse
This project estimates the cost of care in 2003 for four groups of adults with serious mental illness and HIV infection or AIDS, persons with serious mental illness only, persons with HIV infection or AIDS only, and a control group without serious mental illness, HIV infection, or AIDS. It also monitors the extent of cost shifting following the advent of newer antiretroviral and atypical antipsychotic medication by examining differences between inpatient outpatient and medication cost categories in 1996 compared to 2003 for the same four groups. Study participants were adult Medicaid recipients with serious mental illness and/or HIV HIV/AIDS receiving services from a large urban city program in 2003. A comparison of cost of services was done for those with and without mental illness using Medicaid claims records. Costs were also compared with Medicaid participants in the same categories in 1996. In 2003, persons with co-morbid SMI and HIV/AIDS had the highest treatment expenditures at $23,842 per person followed by persons with HIV/AIDS only at $13,183, while the SMI only group was $11,860 per person. The control group had expenditures of $4,793 per person. The 1996 cost estimate for the co-occurring group, using the 2003 consumer price index, was $23,499 compared to $23,842 in 2003. Cost shifts showing a reduction in the proportion of expenditures for inpatient care occurred in all four groups. The greatest shift between 1996 and 2003 occurred, however, in the co-occurring group where inpatient costs went down from 64% to 30%, outpatient costs rose from 17% to 42% and pharmacy costs increased from 19 to 27%. Our results showed the co-occurring group to be the most costly population group which is consistent with our previous study, however, cost differences between 1996 and 2003 were small. Similar to other studies is our finding that the percent of expenditures for inpatient care has decreased significantly. Outpatient care rather than pharmacy was the largest expenditure category which differed from previous study findings. No disparity was seen between the co-occurring group and the HIV only group with respect to medication expenditures.
Revised Estimates of the Cost of Care for Persons with HIV/AIDS in 1996
Aileen Rothbard, ScD; Michael Blank, PhD; Kay Miller, PhD
Data Sources: Medstat
Project Dates: 2006
Funding Sources: National Institute on Drug Abuse
This paper improves on previous cost estimates of treating persons with SMI and HIV/AIDS and examines the extent of disparity in HIV/AIDS drug treatment in the co-morbid SMI/HIV population. Subjects are adult Medicaid recipients from Philadelphia who received a diagnosis of severe mental illness and/or HIV/AIDS between 1985 and 1996, and were Medicaid recipients in 1996, the year the costs estimates were constructed. A comparison of utilization and cost of services was done for those with and without mental illness using Medicaid claims records from State Medicaid Research Files. This study improves on the cost estimates of a prior study by including more comprehensive use of ambulatory care, laboratory, pharmacy and long term nursing home care in addition to inpatient, and outpatient services. Persons with co-morbid SMI and HIV/AIDS had the highest annual medical and behavioral health treatment expenditures at $20,038 per person followed by persons with HIV/AIDS only at $14,713, while the SMI only group was $9038 per person. The control group had expenditures of $6613 per person. Cost of medication in the co-morbid group ($3461) was found to be lower than the combined costs of medication in the HIV and SMI groups ($5176), however, there were fewer persons using antipsychotic drugs in the co-morbid group due to a lower prevalence of schizophrenia. No disparity was seen in the medication treatment and cost for HIV/AIDS in the co-morbid population. Also interesting to note was that, though they did not meet criteria for SMI, many individuals in the AIDS only group had psychiatric and/or drug dependence problems as seen by their use of antidepressant(58%) and anti anxiety (35%) medication as well as inpatient and outpatient psychiatric services. Conclusions: Results are consistent with our previous study showing the co-morbid group to be the most costly population requiring significant care. Also, their expenditure pattern indicates that they are receiving a similar type and amount of medication as those HIV patients without serious mental illness. The AIDs only group, though not co-morbid for serious mental illness, had substantial psychiatric costs. Costs for the two HIV/AIDs population groups average $16,223 per person which is similar to the costs found in the Hopkins study of Medicaid AIDS patients and a four state Medicaid study by NERI looking at AIDS/MH/SA individuals. A follow-up study is needed to see the extent of substitution of drugs for ambulatory and inpatient services for HIV/AIDS related illness and if the SMI are using the same level of antiretroviral drug combinations as other HIV/AIDS patients.
Geriatric Training Program for Physicians, Dentists, and Behavioral and Mental Health Professions
Cynthia Zubritsky, PhD
Data Sources: n/a
Project Dates: 2005-2015
Funding Sources: University of Pennsylvania, Division of Geriatric Medicine
The University of Pennsylvania Geriatric Interdisciplinary Fellowship is a program of the Division of Geriatric Medicine. This Fellowship program prepares medical resident fellows for roles as clinician educator faculty and for certification as appropriate in geriatric medicine, or psychiatry and oral medicine and for leadership in interdisciplinary culturally competent practice. Dr. Zubritsky provides program planning and development and evaluation design for the program.
Penn Research Center for Minority Aging Research
Cynthia Zubritsky, PhD
Data Sources: n/a
Project Dates: 2007-2012
Funding Sources: National Institutes of Health / NCMHHD
This is a P30 program project that provides infrastructure for training and research targeted at minority older adults. Dr. Zubritsky is a Co-Investigator for the community core (Penn MARCH). She is a member of the executive staff, which plans, implements and monitors the fellows' research products, community health interventions, and the development of a minority research recruitment registrar. She is the lead for research translation and dissemination for Penn MARCH products, which includes the fellows' research and community health products.
Delaware Trauma-Informed Care System Transformation
Cynthia Zubritsky, PhD and Aileen Rothbard, ScD
Data Sources: Delaware Division of Substance Abuse and Mental Health Administrative Database
Project Dates: 2010-2015
Funding Sources: Substance Abuse and Mental Health Services Administration
The Delaware Trauma-Informed-Care System Initiative (T-IC), is a systems change intervention designed to develop a trauma-informed mental health and co-occurring care system through: 1) preparing outpatient mental health and co-occurring system providers and peer specialists to build a system of care based on a specified set of principles and values that integrate trauma experiences into the treatment program; 2) provide universal trauma screening and assessment to everyone in the system; and 3) train peer specialists to provide trauma-informed recovery services
Dr. Zubritsky is responsible for the evaluation of all T-IC interventions, including both systems change and agency practice change activities that include the following project activities:: 1) a statewide Advisory Council comprising consumers, clinicians, family members, academics, policy makers, and providers to provide input in the design and implementation of the cultural transformation project and continual guidance over the course of the project; 2) identification of staff attitudes, values and knowledge of T-IC for educational planning purposes; 3) employment of expert consultants to provide support and technical assistance to all staff in the basic principles of T-IC; 5) T-IC supervision by trauma specialists to clinicians and peer specialists to improve recovery outcomes; and 6) the effects of the T-IC program on the system's effectiveness in addressing trauma and recovery. The focus of the evaluation is to determine the project's impact on DSAMH's culture and heightening awareness of T-IC values.
Project Recovery
Cynthia Zubritsky, PhD
Data Sources: Beaver County PA Office of Behavioral Health Administrative Database and PA Health Choices Database
Project Dates: 2010-2015
Funding Sources: Substance Abuse and Mental Health Services Administration
Project Recovery builds on a transformation process already underway in Beaver County, Pennsylvania, developing a countywide peer-driven, recovery-oriented system of care that is culturally and linguistically competent and utilizes evidence-based and best practice interventions. Beaver County Behavioral Health and its stakeholders are committed to providing the services and supports needed to offer all county residents a quality life in their community. In Dr. Zubritsky's role as an evaluator for Project Recovery, she is developing and implementing NOMs data collection and designing an integrated evaluation plan that measures the following: 1) effective behavioral health prevention through the implementation of evidence based screening, early intervention practices and collaboration between physical and behavioral health providers ; 2) implementation of a trauma informed care framework by expanding the implementation of Seeking Safety to new populations; 3) creation of an electronic web-based service plan application to support outreach, collaboration, and single point of accountability through a universal platform through which peers and providers can work with peers to create, maintain, and share service, crisis, and WRAP plans; and 4) development of a housing support team, including a Peer Specialist, within Beaver County's Permanent Supported Housing program; and 5) development of expanded employment options through the use of mobile employment support coordinators who will implement the supported employment EBP.
Delaware C0-Occurring Systems Integration Grant
Cynthia Zubritsky, PhD and Aileen Rothbard, ScD
Data Sources: Delaware Division of Substance Abuse and Mental Health Administrative Database
Project Dates: 2007-2012
Funding Sources: Substance Abuse and Mental Health Administration and Delaware State Department of Health and Social Services
The Substance Abuse and Mental Health Service Administration (SAMHSA) awarded a Co-occurring State Incentive Grant (COSIG) to the State of Delaware, Delaware Department of Health and Social Services (DHSS), in 2007. The goal of the intervention is to increase state capacity to provide integrated treatment for MH and SA through a practice-change intervention. System wide training as well as agency consultations using "live" consumer interviews, role playing &/or case presentations. An additional intervention has been the use of a strategy developed by the Network for the Improvement of Addiction Treatment (NIATx) to provide the Change Leader Academy to designated staff from participating agencies. The trainees or Change Leaders are provided TA aimed at changing practices within their agencies. Each Change Leader developed a team and participated in conference calls as well as day-long trainings. The evaluation will assess the extent to which the state changed its organizational infrastructure to improve COD treatment, the degree to which providers increased their case finding of individuals with COD using screening and assessment tools, the amount of integration that occurred as a result of training and consultation, the perception of staff and consumers with regard to the changes.
Mental Health and Aging Integrated Case Conference Series
Cynthia Zubritsky, PhD
Data Sources: Pennsylvania Department of Public Welfare
Project Dates: 2009-2012
Funding Sources: Pennsylvania Coalition for Mental Health and Aging
This consultation model provides monthly videoconferences for persons working in Pennsylvania's mental health or aging system. The program teaches individuals within each system to work across systems to develop collaborative case conferences. Two difficult cases are presented each month, with audience technical assistance.
Older Adult Peer Specialist Initiative
Cynthia Zubritsky, PhD
Data Sources: Pennsylvania Department of Public Welfare
Project Dates: 2006-2012
Funding Sources: Pennsylvania Department of Public Welfare
Funded through a NASMHPD Transformation Technical Assistance Grant from SAMHSA, the Older Adult Peer Specialist (OAPS) project has included three major goals: the development of an Older Adult and Peer Specialist Curriculum to guide the training of peer specialists in their work with older adult; training of OA PS and OA PS Trainers; and development of an internship program for OAPS. Training slots are nationally competitive.
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text:
I'll warn you in advance that this column will reveal what a total pussy I am, but here goes anyway.
So I've been continuing to watch the American version of "The Office" for the last few years even as it first grew lame, then terrible, then borderline unwatchable. It introduced genuinely unfunny characters, stopped and started plot threads that led nowhere, and generally felt like a meandering waste of time.
I couldn't figure out why I was still bothering to watch this show that had become so totally uninteresting to me that each new episode felt like homework. It was some kind of TV inertia I have in which once I've invested any time and thought into characters I must see how those characters develop as if they're my own friends—even if they've become a boring and pale version of their more interesting British selves (pun intended).
I was reminded of just how far the American version had strayed from Ricky Gervais's original creation when my roommate Pat began watching it for the first time on Netflix. Even though the American version is a carbon copy in theory, the British version was so much darker, meaner, and bleaker that it's practically night and day compared with the emo American version.
Anyway, all this is to say that if you at any point enjoyed the American "Office" I highly recommend you check out the series finale.
It hit so many totally perfect notes that it almost made up for slogging through the last three seasons of the show. It was funny, poignant, and even insightful about the ways in which this funny little life flows. Of course most of this comes out through the viewer's central avatars in the show, Jim and Pam, a relationship that ceased being interesting by about season 4, but which comes back to life in this final episode in extremely thoughtful ways. The central conceit is that the castmates have all become minor celebrities after their documentary aired and are reunited a year later to talk about what's happened since.
Unlike a lot of the shows using the faux-documentary format ("Parks and Rec", "Modern Family"— it feels like that ploy became ubiquitous for a brief moment), here we see the results of a camera crew following these people around for nine years. There is even a rather smart underlying dialogue about what it means to be famous in America, and how people of all stripes can project their own hopes and desires upon those objects of fame.
I'll say this: I watched the episode with my friends Joe and Laurie while their little baby slapped me in the face and played with my beard stubble (Riley either bawls her eyes out every time she sees me walk through door or slaps me around; much like my relationship with most women).
All three of us kind of sat staring at the screen, not looking at each other as wave after wave of laughter and lump-in-throats hit us. Like Joe said, "I wish you two weren't here so I could cry."
Which is why I watched it later on my own. Even if you've skipped the last three to five years of the show, give the series finale one last chance.

subset: commoncrawl


text:
Spyware Terminator 220.127.116.11
Downloads: 739772
File size: 632KB
Requirements: Windows (All Versions)
License: Freeware
Spyware Terminator 22.214.171.124 Change Log
Powersaving options
* This version of Spyware Terminator brings a specially designed feature for laptop users. Portable PC recognizes when the laptop is running on battery power and automatically postpones the planned scan until it is plugged in again.
Real-Time Protection Adjustments
* The behavior of Basic Mode, one of two real-time protection modes, has been significantly modified in this version of Spyware Terminator. Problems with accidental blocking of some items have been solved. Users of Basic Mode will also receive top protection against malware with minimal alerts, thanks to our extensive database of nearly 1,000,000 items.


text:
Derry business filling the soaring demand for classic carsBy BARBARA TAORMINA
Union Leader Correspondent
July 24. 2013 9:32PM
For Stephan Condodemetraky, the vintage car business ultimately comes down to one basic thing.
"This business is about putting a smile on someone's face," said Condodemetraky, who owns Dusty Old Cars, a classic car dealership in Derry.
And there are a lot of smiles around the antique auto world these days. Despite the sluggish economy, sales of collectible cars have been on a roll for the past couple of years.
Buyers are scooping up Mustangs, Thunderbirds, Chevy Bel Airs and other makes and models that ruled the roads during the '50s, '60s and '70s. And there's also a demand for vintage Ferraris, Bentleys, Jaguars and other luxury vehicles.
In New Hampshire, where there is a strong affection for just about anything with wheels and a motor, vintage cars are a big slice of the summer economy.
"There's a car show almost every night of the week," Condodemetraky said.
This weekend, old cars will move into Holden Stadium at 67 Amherst St. on Saturday in Nashua for the city's annual vintage car fest from noon to 4, and the Field of Dreams Antique Auto show in Amherst will hold its July show beginning at dawn on Sunday at 157 Hollis Road.
And when vintage car collectors aren't strolling through shows, they are often parading in community celebrations, riding along on special vintage car cruises or just enjoying the way they look and feel behind the wheel of a classic car.
Vintage car dealers are the hub of the antique auto industry, and there are a range of dealerships in New Hampshire. Car collectors can spend hundreds of thousands of dollars on rare editions and models.
Earlier this month, a 1954 Mercedes racer set a new record for the highest price paid for a vintage car when the final bidder offered $29.6 million at a sale in London. The former record was $16 million bid for a 1957 Ferrari 250 Testa Roassa.
Although that sector of the vintage car market makes headlines, Condodemetraky said it's the top sliver of the vintage car customer base. The much larger vintage car market is made up of car enthusiasts looking for an affordable ride.
"I would say that $5,000 to $10,000 is our sweet spot," Condodemetraky said.
But whether a buyer spends $5,000 or $500,000, antique autos are assets that have an impressive record of appreciation. Unlike new cars that lose value with every mile, vintage cars in good condition that are well maintained increase in value over time.
Condodemetraky said some buyers are collectors interested in cars for their historical significance, but the majority of vintage car enthusiasts are driven by nostalgia.
"It's more about their personal history and memories," he said. "They want to relieve their high school days."
Bryan Barbin, who runs Cutting Edge Industries in Candia with his brothers Alan and Craig, sees the same trends in the vintage car market.
"We help build peoples' dream cars," Barbin said. "Mostly what we do is restore the types of cars people had in high school."
The Barbin brothers grew their business from a shop started by their father, and they now have a team of eight service technicians who restore antique autos. Cutting Edge can fix all the basic equipment and systems and make sure a vintage car runs well. For higher stakes investments, the Barbins will research a vehicle and restore it with complete accuracy and pain-staking detail.
"Everyone's needs are different," Barbin said.
Cutting Edge is one of many local businesses that specialize in vintage car restoration.
At Dusty Old Cars, a service team works on all part of the cars inside and out. At other shops, owners specialize in restoring emblems or re-chroming fixtures.
Beyond the buying, selling and restoration work, the vintage car industry generates jobs and revenue in the insurance industry, advertising and accessories. And the full schedule of shows, exhibits and parades draw big crowds that pump up business in local restaurants and shops.
Although vintage cars are a global business, Condodemetraky said New Hampshire is a natural antique auto hot spot.
"We have a small but beautiful oceanscape and hundreds and hundreds of miles of tree-lined country roads," he said.
Although the vintage car industry is humming, there are some dealers who see problems ahead.
While crowds today may cheer when they see a Packard or an old Ford in a local parade, some dealers worry that an eco-minded public may eventually want less environmentally friendly vintage cars off the road.
And vintage cars require mechanics who can diagnose a problem by the sound of an engine or the smell of the fumes. Today's mechanics are dependent on computers to assess problems, and the skills needed to maintain antique cars are dying out.
Don Haynes, who has a small antique car dealership in Tamworth, also sees the vintage car movement tied to the current generation of retiring baby boomers who have time and disposable income to spare.
"They want the cars they drove when they were younger," he said.
But Haynes doesn't see much interest in vintage cars among younger people who have grown up driving cars that are safer, more fuel efficient but lack the flair and excitement of the older models.
"I don't think you'll see a lot of business when the younger generation moves up," he said.
But Condodemetraky thinks the antique cars will maintain a devoted following.
"It's about chrome, steel and Americana," he said.


text:
The interim Blues manager wanted to snap up his compatriot during his time in charge at Anfield but was unable to persuade Villarreal to sell the playmaker, who eventually signed for Arsenal from Malaga last summer.
"The chairman there [at Villarreal] wanted to keep the team and didn't want to lose one of his best players," Benitez told reporters. "It wasn't possible to sign him, because it was a big risk with the amount of money we had to spend.
"At the time he was a winger and not playing between the lines or as a second striker. We knew he could be a great player, but he was [going to cost] too much at the time and we could not afford him.
"To come to England and settle down is not just down to the quality of the player but sometimes it also depends on the environment and, in the case of Cazorla, he is doing well at Arsenal."
Benitez's Chelsea side has struggled at home in the Premier League of late, only winning one of its last seven games to fall 13 points behind league leader Manchester United. The manager argues that a derby against a side such as Arsenal is the perfect tonic after Wednesday's 2-2 draw at home to Southampton, though.
"After a draw at home, we have a top side coming to us and that is good for us," Benitez said. "It gives us extra motivation, and we will be focused. This is different from a normal game because the atmosphere is different."


text:
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text:
Sorry this is so long, I just wanted to put as much background as I could if that helps.
I'm a second time mother, but this is my first baby breastfed more than a few weeks. That said, I've read up on just about everything I could. But I can't really find any answers for this. My 10 week old boy was breastfeeding pretty well. He is pretty fat. I weighed him with me on our scale and it seems that he is about 16 lbs, though I have to take him to his 2 month appointment this week (missed the last one). At around 7 weeks though, he started to latch and unlatch every few seconds. I noticed I have had overactive letdown, with some spraying, but only in one breast (not sure if it counts as overactive letdown without spraying?) and I noticed this after his 6 week growth spurt. Oh when I started side lying with him around this period of frequent waking, he would only take a little and fall asleep. When he started having green poops, I switched to block feeding to correct both issues and this went away. But he seemed to get even fussier and I was not sure if I had diminished my milk supply. Oh yeah, around this time of introducing side lying sleeping, he began to become very gassy as well, lots of passing gas but I attributed this to me not burping him when we sleep. Also during this time, we went on a trip out of town and we could not even get back out of town because he hates his car seat and wanted to feed for 3 hours, all the while latching and unlatching as we sat on the highway with both me and my husband frustrated and confused.
During weeks 7-9 he constantly constantly nursed and didn't sleep and suddenly became unputdownable. I figured he was comfort nursing because he would latch, unlatch, get mad about milk coming and started to wake up to nurse every hour and would wake up quickly from naps. I even got an oversupply and engorged from all the comfort nursing. Previously to this, he was sleeping for about 2 hours at a time, even with an occasional 3 hour nap and one 3 hour stretch at night (this happened for only one glorious week at about 6 weeks before the growth spurt). I have since figured out that at some point, probably during or after the previously mentioned trip, he became chronically overtired as I was totally missing his cues and he is the sort that will never stop looking around, being alert and is happy until he's screaming.
Now that I've figured out that he was overtired I've been weaning him off comfort nursing so much by trading it for rocking when he no longer eats without crying anymore (which was the way I used to get him to sleep). He eventually stopped wanting to suck so much and allowed me to rock him. He's starting to sleep more at night with about waking every 1.5 to 2 hours and I have even been able to put him down in his cosleeper/bassinet for one nap and am currently praying he'll finish this current one. So things are getting better and at night he nurses (while sleepy) pretty well, like normal.
But the problem is this - when he is fully awake, he STILL nurses for a few seconds, pulls off, takes a few breaths or looks around, relatches, rinse and repeat. Sometimes he'll even nurse for a few minutes but then he'll pull off and milk will be dripping everywhere (not spraying, just dripping very quickly). Sometimes after a few minutes of this I get frustrated and put him down to play or in his swing but in about 5-10 minutes he is screaming for food again and then the same cycle starts. This continues on until he changes to crying in between latches and then I know he's tired and I rock him to sleep.
Also, sometimes he falls asleep but wakes up soon after, hungry. And he is not draining the breast at all during the day, though this may have something to do with my oversupply. What is going on here? I am so frustrated that I am beginning to hate nursing and he refuses pacificers, doesn't really drink from the bottle (he sometimes drinks a little, most times he won't though I don't get the chance to pump much so I haven't offered it much lately) and I feel like if I give up, he will starve. I was wondering if it could be reflux or thrush but it doesn't seem like we match those symptoms. I read about distractible babies but he seems too young for this and is it really this bad when they are?
I know this is a lot of info but I've spent weeks researching this and I have no definitive answers and I don't know if something is wrong that I'm not seeing. I've got no confidence that his ped will either since these are the people who told me when he was a few days old to start supplementing and not letting him feed more often than every 2 hours because my breasts needed time to drain and babies get all of their nourishment within 15 min and to not let him nurse longer than that. Yes, I know.
Thank you so much for any guidance. I used to love breastfeeding and look forward to it but now I'm just looking for any way to get out of it.