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Special Report
Preventive Interventions
Under Managed Care: Mental Health
and Substance Abuse Services
Services
Recommended
for Consideration
by Managed Care
Organizations
The articles reviewed for this document describe a wide range
of preventive behavioral health interventions, research subjects,
evaluation designs, and outcomes. While the evidence
of positive outcomes in all of these articles merits the attention of MCO
stakeholders, six interventions are recommended for MCO consideration
because:
- their effectiveness has been demonstrated
by two or more studies included in this
review,
- their appropriateness for provision in a
managed care or referral setting has been
explicitly stated or is apparent;
- and their feasibility for MCO coverage from
a cost perspective has been documented
or suggested.
The fact that some of the services
described in reviewed studies are not included
on this list does not imply that they
should not receive MCO consideration;
rather, it means that additional information
is needed about the effectiveness of those
programs and services in relation to desired
managed care outcomes and cost impact.
The citations abbreviated parenthetically
after each listed service refer to the supportive
articles included in this review. The inter
ventions in the cited articles are similar but
not identical; their adoption by an MCO
should be tailored to the characteristics of its
providers and members. Detailed summaries
of these articles are provided in Appendix C.
1. Prenatal and infancy home visits (Field et
al., 1982 [reference 8]; Olds et al., 1993
[reference 2]; Ramey & Ramey, 1992
[reference 5]). These articles focused on
women with high-risk pregnancies,
teenage mothers, and low-birthweight
infants born prematurely. The timing of
periodic home visits varied, ranging from
the prenatal period until the child reached
3 years of age. Home visits were made by
nurses in one project and by a psychology
graduate student teamed with a Comprehensive
Education Training Act (CETA)
aide in another. The content of the home
visits in one study focused on maternal functioning and in others on the training
of mothers to stimulate their infants.
Significant findings included fewer subsequent
pregnancies and live births, greater
spacing between births, less alcohol and
drug impairment, and less child abuse and
neglect among mothers receiving home
visits; greater weight and better scores on
motor developmental tests among infants
whose mothers received intervention; and
reduced incidence of mental retardation
among infants whose mothers received
intervention.
2. Targeted cessation education, and counseling
for smokers, especially those who are
pregnant (Cummings, Rubin, & Oster,
1989 [reference 26]; Marks, Koplan,
Hogue, & Dalmat, 1990 [reference 1];
Windsor et al., 1993 [reference 3]).
Subjects in these articles included a birth
cohort of women who smoked during
pregnancy, pregnant smokers recruited
through county maternity clinics, and a
hypothetical group of male and female
smokers receiving routine medical care.
Interventions consisted of a 15-minute
counseling session with a nurse or health
educator, supplemented by written materials
and two followup telephone calls; a
15-minute counseling and skill development
session with a trained health counselor,
supplemented by clinical patient
reinforcement, social support, newsletter
information, and mention in a prenatal
education class; and 4 minutes of physician
advice to quit smoking, supplemented
by a self-help booklet and a 1-year followup
visit. The birth cohort model study
estimated savings of $3.31 of the cost of
caring for low-birthweight infants in a
neonatal intensive care unit for every dollar
spent on smoking cessation intervention. In the hypothetical patient group,
brief physician advice was estimated to
increase the cessation rate at 1 year by
2.7%. In the maternity clinics, the intervention
produced a 14.3% quit rate compared
with an 8.5% quit rate in the control
group.
3. Targeted short-term mental health therapy
(Finney et al., 1991 [reference 15];
Goldberg et al., 1981 [reference 41]). In a
study of children up to the age of 15 who
received one to six targeted behavioral
therapy sessions with their parents from
doctoral-level pediatric psychologists or
predoctoral clinical psychology interns,
those with behavioral problems reduced
their medical encounters by almost a
third, while those with toileting problems
reduced their medical encounters by
almost one-half. In another group of individuals
who sought short-term psychotherapy
from a psychiatrist or other
registered psychotherapist on an approved
list of community practitioners, index
cases decreased days of medical hospitalization
significantly compared with
matched controls.
4. Self-care education for adults (Fries et al.,
1992 [reference 40]; Kemper, 1982 [reference
29]; Kemper et al., 1993 [reference
43]; Leigh et al., 1992 [reference 51];
Vickery et al., 1983 [reference 32]; Vickery
et al., 1988 [reference 52]). Five of the
six cited studies were conducted in managed
care settings; the sixth was worksite
based. The interventions addressed health
promotion and self-care issues that
encompassed substance use and mental
health. Interventions included group education
workshops led by a nurse practitioner,
supplemented by a self-care guide
and videotapes; written materials, a telephone information service staffed by a
nurse coordinator, and an individual
health evaluation and planning conference
with a trained nurse; computer-based,
serial, personal health risk reports
supplemented by individualized recommendation
letters and written materials;
access to a self-care center; one-on-one
education sessions with physicians; and
slide-tape shows. Results included an estimated
28% savings in laboratory costs
and 24% savings in x-ray costs between
experimental and control groups; a 17%
decrease in total medical visits, and a
35% decrease in minor illness visits in
experimental versus control groups.
Significant improvements in health risk
behaviors were noted, including smoking,
alcohol use, and reported stress; decreases
in ambulatory physician visits ranging
from 7.2% to 24%; and a decrease of
15% in total medical visits in the experimental
group compared with controls.
In one study, for every dollar expended
on the program, an estimated $5 were
saved in direct health care costs for physician
visits and hospital days.
5. Presurgical educational intervention with
adults (Devine & Cook, 1983 [reference
35]; Devine et al., 1988 [reference 36];
Egbert et al., 1964 [reference 38]). In one
of the cited studies, the intervention consisted
of a workshop to enable staff nurses
to provide psychoeducational care to adult
surgical patients. Interventions described
in the other two articles included information
for patients about what to expect;
skills training to help patients prevent
complications or reduce anxiety; psychosocial
support with a health care
provider to reduce anxiety or enhance
ability to cope with hospitalization, supplemented
with printed and taped materials;
and visits to patients by an anesthetist
before and after surgery to provide information
and self-care guidance. Interventions
were associated with less use of
sedatives, antiemetics, hypnotics, and narcotics
as well as earlier discharge from the
hospital.
6. Brief counseling and advice to reduce
alcohol use (Bien et al., 1993 [reference
33]; Fleming et al., 1997 [reference 39];
Fleming et al., 1999 [reference 53]; World
Health Organization, 1996 [reference
50]). The articles reviewed studies conducted
in the United States and internationally.
Interventions included between
5 and 15 minutes of advice or counseling
on reducing alcohol consumption provided
by physicians, nurses, psychologists,
or other professionals. In some studies,
subjects also received a workbook or
informational or self-help materials. Other
intervention components included follow-up
visits or telephone calls for reinforcement.
Significant reductions in alcohol
consumption were documented.
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