Greg Greenberg | Yale University (original) (raw)
Papers by Greg Greenberg
ABSTRACT Mental health care organizations have been an important laboratory for sociological rese... more ABSTRACT Mental health care organizations have been an important laboratory for sociological research. Classic studies on state mental hospitals focused on how the social structure of the hospital shaped therapeutic outcomes (Goffman, 1961; Strauss, Schatzman, Burcher, Ehrlich, & Sabshin, 1964). Organizational theorists (Etzioni, 1960; Perrow, 1965) found that state mental hospitals provided rich materials for understanding complex organizational structures and behavior, which led to significant advances in organizational theory. All of the aforementioned studies made significant contributions to sociological understanding of organizational control and power, and mental health care organizations continue to be excellent sites for understanding changing forms of organizational control as well as furthering understanding of conflict between professional and bureaucratic control. As organizational theory developed to include inter-organizational relations and networks of organizations, research on mental health care has contributed to knowledge about how organizations manage contradiction, conflict, and ambiguity (Meyer, 1986; Scott, 1983). Organizational theory also provides a powerful model for understanding changing systems of mental health care (Scheid, 2004; Schlesinger & Gray, 1999).
Journal of Health Care for The Poor and Underserved, 2003
Many researchers have suggested that the implementation of managed care may lower access to, and ... more Many researchers have suggested that the implementation of managed care may lower access to, and quality of, health care services for minorities. However, very little empirical data examining this issue exists. To examine it, the authors used a study design that was both cross-sectional and longitudinal in that they surveyed Medicaid recipients in two counties at two points in time; one of the counties began delivering services through managed care between the two survey periods. Their results indicate that, overall, managed care had neither a positive nor a negative effect on African Americans' access to health care services in either absolute terms or relative to whites'. In addition, race was not found to be associated with satisfaction. However, a Medicaid recipient's race was found to negatively affect his or her access to service under both managed care and fee-for-service systems.
Journal of Health Care for The Poor and Underserved, 2003
Many researchers have suggested that the implementation of managed care may lower access to, and ... more Many researchers have suggested that the implementation of managed care may lower access to, and quality of, health care services for minorities. However, very little empirical data examining this issue exists. To examine it, the authors used a study design that was both cross-sectional and longitudinal in that they surveyed Medicaid recipients in two counties at two points in time; one of the counties began delivering services through managed care between the two survey periods. Their results indicate that, overall, managed care had neither a positive nor a negative effect on African Americans' access to health care services in either absolute terms or relative to whites'. In addition, race was not found to be associated with satisfaction. However, a Medicaid recipient's race was found to negatively affect his or her access to service under both managed care and fee-for-service systems.
Administration and Policy in Mental Health, 2003
The authors analyzed changes in access to and use of mental health services by minorities in the ... more The authors analyzed changes in access to and use of mental health services by minorities in the Veterans Health Administration during a period of major system change (1995–2001). Blacks had poorer outpatient access than Whites during this period of change, but were not further disadvantaged over time, and their access to care improved relative to Whites on some measures. For Hispanics, there was a trend toward greater inequality in the delivery of outpatient mental health care. These results suggest a need to monitor and address the differential impact on minorities of changes in mental health service delivery.
General Hospital Psychiatry, 2006
Objective: Advanced practice nurses (APNs), including clinical nurse specialists and nurse practi... more Objective: Advanced practice nurses (APNs), including clinical nurse specialists and nurse practitioners, now have prescribing privileges in all states. This study examined the proportion of Department of Veteran Affairs (VA) mental health patients who were seen by any prescribing professional and specifically the proportion and characteristics of patients who were treated exclusively by APNs. Method: Logistic regression models were used to examine data on all patients who received care in VA specialty mental health clinics in 2002 (n = 767,920). We first identified patient characteristics independently associated with prescriber contact and, secondly, among those with prescriber contact, exclusive contact with an APN. We also compared characteristics of patients seen exclusively by an APN with those who saw both a physician and an APN. Results: The strongest predictors of both whether a veteran saw a prescriber (66.6%) and whether that prescriber was exclusively an APN (6.7%) were indicators of severity. Specifically, more severe diagnoses, such as schizophrenia or bipolar disorder, receipt of VA disability payments and greater service use increased the odds that a veteran would have had a prescriber contact, decreased the odds that they would see an APN exclusively and, among those who saw an APN, increased the odds that they would also see a physician. Conclusions: Patients who see physician prescribers have more severe mental health problems than those who see APNs. Our results indicate that APNs and physicians treat distinguishable patient populations, suggesting that APNs may not be substitutes for physicians. D
Journal of Behavioral Health Services & Research, 2003
Continuity of care (COC) has often been viewed as a crucial indicator of treatment quality for pa... more Continuity of care (COC) has often been viewed as a crucial indicator of treatment quality for patients with severe psychiatric or addictive disorders. However, the relationship between COC and clinical outcomes has received little empirical evaluation. This study used hierarchical linear modeling to examine the relationship between six indicators of COC and seven outcome measures addressing symptoms, substance abuse, and social functioning. Patient interviews were conducted with 1576 veterans 3 months after their discharge from one of 22 residential work therapy programs for the treatment of severe substance abuse. Few significant relationships were found between COC and outcome measures in analyses conducted at both the client and program level and fewer than half of these show better outcomes with greater COC. When a Bonferroni corrected P level of P <0.0012 was used, none of the relationships were statistically significant. Although there were significant relationships between outcomes and measures of services received during residential treatment, postdischarge COC does not seem to be related to improved outcomes, at least when examined following long term intensive residential treatment. Thus, our results are specific to the context of aftercare following long-term residential rehabilitation and indicate that the value of standard performance measures may vary by treatment context.
Criminal Behaviour and Mental Health, 2008
Aims This study sought to investigate the rates and correlates of homelessness (i.e. living on th... more Aims This study sought to investigate the rates and correlates of homelessness (i.e. living on the street or in a homeless shelter), including mental illness, among US adult state and federal prison inmates (ASFPIs).Method Data from a national survey of ASFPIs based on a random sampling survey (N = 17,565) were used to compare the homelessness rate among AFSPIs with that in the general population. Logistic regression was then used to examine the association of homelessness among ASFPIs with factors including symptoms, treatment of mental illness, previous criminal justice involvement, specific crimes, and demographic characteristics.Results Nine percent of ASFPIs reported an episode of homelessness in the year prior to arrest, 4–6 times the estimated rate in the general US adult population after allowing for age, race/ethnicity, and gender. In comparison to other inmates, these homeless inmates were more likely to be currently incarcerated for a property crime, but also to have had previous criminal justice system involvement for both property and violent crimes, to suffer from mental health and/or substance abuse problems, and to be more likely to have been unemployed and with a low income.Conclusions Recent homelessness is far more common among ASFPIs than the general population. Prior incarceration, mental illness, substance abuse and disadvantageous socio-demographic characteristics were all found to be associated with homelessness among prison inmates, suggesting that there are several important factors in addition to efforts to survive with limited resources through criminal acts that influence the rates of homelessness among incarcerated individuals. Published in 2008 by John Wiley & Sons, Ltd.
Administration and Policy in Mental Health, 2010
This study sought to investigate correlates of past homelessness, especially mental illness and s... more This study sought to investigate correlates of past homelessness, especially mental illness and substance abuse, using data from the National epidemiological survey on alcohol and related conditions (NESARC), a large nationally representative survey conducted in 2001–2002. Multivariate analyses showed that the factors most strongly related to past homelessness were diagnoses of behavioral health conditions which showed consistently stronger association than sociodemographic characteristics, measures of economic well being, or general health indicators. The results presented here confirm in a nationally representative sample a number of single site studies that have also demonstrated the over representation of both mental illness and substance abuse disorders in homeless populations.
Administration and Policy in Mental Health, 2004
This study used hierarchical linear models to analyze post-discharge data among 17,130 veterans w... more This study used hierarchical linear models to analyze post-discharge data among 17,130 veterans who received inpatient VA mental health services between 1995 and 2001, in order to determine whether changes in mental health service affected inpatient satisfaction. In models without covariants, half the satisfaction measures increased while the other half indicated no significant change. After adjusting for changes in patient characteristics, however, nine measures indicated no change and seven showed significant declines. Demonstrating the importance of risk-adjustment, satisfaction appeared to increase over time prior to risk adjustment, but declined after adjusting for changes in patient characteristics that were associated with patient satisfaction.
Journal of Health Care for The Poor and Underserved, 2006
This study examines housing status at the time of hospital discharge in a national sample of 3,50... more This study examines housing status at the time of hospital discharge in a national sample of 3,502 veterans who were homeless at admission to a Veterans Health Administration (VHA) medical center. A supplemental survey on homelessness was added to the annual VHA inpatient census over a 4-year period (1995 through 1998). Data from this survey were used to identify homeless veterans hospitalized on the final day of the fiscal year and to document their housing status at discharge. A signal detection technique, Receiver Operating Characteristic analysis, was used to identify predictors of housing status at discharge. At discharge, only 13% of the veterans in our analytic sample were literally homeless, 40% were doubled up, and 33% were transferred to another an institution; only 13% were living independently. Housing status at admission (specifically, staying with friends or family temporarily rather than literally homeless), treatment in a psychiatric or substance abuse program rather than a medical program, and a greater income level or access to VHA benefits were found to be associated with better housing outcomes. As one might expect, homelessness was infrequently resolved during an acute inpatient hospitalization, but few veterans returned to literal homelessness at the time of discharge.
International Journal of Offender Therapy and Comparative Criminology, 2012
Journal of Health Care for The Poor and Underserved, 2010
This study uses data from a nationally representative epidemiologic survey, the National Comorbid... more This study uses data from a nationally representative epidemiologic survey, the National Comorbidity Survey Replication, to investigate the association of mental health and substance use disorders, along with other factors, with past homelessness. Approximately 5% of the 5,251 adults reported having been homelessness. Multivariate analysis showed the strongest independent risk factors for past homelessness were past receipt of welfare payments (odds ratio [OR]=5.7), incarceration for 27 or more days (OR=3.9), exposure to personal violence (OR=2.7), lifetime substance use disorder (OR=2.4), and Black race (OR=2.1). Several non-substance use psychiatric disorders were also significantly, if less strongly (OR 1.4 to 1.6), associated with past homelessness. Past homelessness is associated with a broad array of sociodemographic, economic, and mental health problems. While the association of both substance use and psychiatric disorders with past homelessness was quite strong, non-substance use psychiatric disorders was not as strong an independent risk factor as substance abuse disorders.
Psychiatric Quarterly, 2007
Public support payments may facilitate exit from homelessness for persons with mental illness. We... more Public support payments may facilitate exit from homelessness for persons with mental illness. We examined data from 10,641 homeless veterans contacted from October 1, 1995 to September 30, 2002 in a collaborative outreach program designed to facilitate access to Department of Veterans Affairs (VA) disability benefits. Those who were awarded benefits (22% of contacted veterans) were more likely to report disability, poor to fair self-rated health, and were more likely to have used VA services in the past. Thus, this program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.
Psychiatric Quarterly, 2004
Continuity of care (COC) is often used as an indicator of treatment quality for patients with sev... more Continuity of care (COC) is often used as an indicator of treatment quality for patients with severe psychiatric or addictive disorders. However, few studies have examined the relationship between measures of COC and treatment outcomes. This study used standard regression models to examine the strength of the association between continuity of care measures and health outcomes for a sample of female veterans newly entering outpatient treatment for PTSD. There were few consistently significant associations between COC and outcome measures. Four months following program entry only one measure of treatment process, commitment to treatment, was positively associated with one or more continuity of care measures and several COC measures were associated with poor outcomes. Eight months following program entry patients with greater COC during the first four months of treatment had greater declines in violent behavior and PTSD measurements and larger increases in global functioning. However, when a Bonferonni corrected alpha of P <.001 was used to adjust for multiple comparisons, none of the relationships remained statistically significant. Thus, this study provides only weak and inconsistent evidence of the clinical benefits of continuity of care.
Psychiatric Quarterly, 2006
There has been a growing interest in the implementation of evidence-based specialized mental heal... more There has been a growing interest in the implementation of evidence-based specialized mental health programs. However, there has been little study of the effectiveness of these programs in comparison with standard mental health care in real world mental health systems. This study used a national sample of patients from the Veterans Health Administration to compare changes in mental health status in various specialized mental health outpatient programs and in general psychiatric clinics. Hierarchical linear models were used to compare the association of both regularity and intensity of care in six specialized mental health programs with GAF change scores in patients treated in general psychiatric clinics. While improvements were observed in all programs, two specialized programs performed better overall than general psychiatric care, one was not significantly different, and three had poorer outcomes than general psychiatric clinics. Programmatic differences in target populations accompanied by imperfect risk adjustment for population differences most likely explain why these results differ from those observed in clinical trials. While the analytic strategies demonstrated here may have wider applicability to comparative performance assessment, this study provides a cautionary tale concerning the limits of conclusions that can be drawn from large scale outcomes monitoring efforts.
Journal of Behavioral Health Services & Research, 2003
Evaluation of the quality of outpatient treatment for patients with severe psychiatric or addicti... more Evaluation of the quality of outpatient treatment for patients with severe psychiatric or addictive disorders has often focused on the assessment of continuity of care (COC) as measured with administrative data. However, there has been little empirical evaluation of the relationship of measures of COC and treatment outcomes. This study used hierarchical linear modeling to examine the relationship between 6 indicators of COC and 6 outcome measures in a multisite monitoring effort for veterans with war-related posttraumatic stress disorder. There were few consistently significant associations between COC and outcome measures. Although measures of COC at the level of individual patients were associated with reductions in substance abuse symptoms, when COC measures were averaged to the site level and examined with hierarchical linear modeling models, thereby reducing the impact of intrasite selection bias, they were not associated with any desired outcomes. COC measures, at least in the sample used for this study, are not consistently associated with desirable client outcomes and may therefore be less than ideal performance measures in outcome evaluations following inpatient treatment, except to the extent that COC is considered to be an intrinsic indicator of higher quality regardless of its relationship to outcomes.
Psychiatric Quarterly, 2009
Data derived from the 2002 Survey of Inmates in Local Jails and the 2000 National Survey of Veter... more Data derived from the 2002 Survey of Inmates in Local Jails and the 2000 National Survey of Veterans show that having mental health problems in addition to such sociodemographic characteristics as being a member of a minority group, not being married, having less education, and being younger are risk factors for incarceration among veterans, as they are for the general population. As in previous studies veterans who served during the Vietnam Era and to an even greater extent, those who served in the early years of the All Volunteer Force were at greater risk of incarceration than veterans from the most recent period of the AVF, after controlling for age and other factors.
Medical Care, 2003
To investigate the impact of implementing service line organization on the delivery of mental hea... more To investigate the impact of implementing service line organization on the delivery of mental health services. Survey data on the implementation of service lines and facility-level administrative data on the delivery of mental health services at 139 Department of Veterans Affairs medical centers (VAMCs), over a 6-year period, were used to examine the relationship between service line implementation and subsequent performance in 4 areas: 1) continuity of care (COC), 2) readmission after inpatient discharge, 3) emphasis on community-based mental health care (as contrasted with inpatient care), and 4) maintenance of proportionate funding for mental health care. Models were analyzed using hierarchical linear modeling techniques to control for potential autocorrelation. Of 6 COC measures, 1 strongly improved in all years following service line implementation, and 3 of the 5 other measures demonstrated improvement in the first year. One of 2 readmission measures showed a decline in the first year after service line implementation. Service line implementation was associated with only 1 indicator of increased emphasis on community-based mental health care (and only in the first year), whereas 3 of the 4 other measures suggested a decline in such emphasis. Lastly, although there were increases in per capita mental health expenditures 3 or more years after service line implementation, 2 related measures indicated that service line implementation was associated with a decline in mental health expenditures relative to nonmental health services. Service line implementation was associated with significant, although predominantly short-term, improvement in patient level variables such as continuity of care and hospital readmission, but less so with regard to institutional measures addressing emphasis on outpatient care and maintaining proportionate funding of mental health services.
ABSTRACT Mental health care organizations have been an important laboratory for sociological rese... more ABSTRACT Mental health care organizations have been an important laboratory for sociological research. Classic studies on state mental hospitals focused on how the social structure of the hospital shaped therapeutic outcomes (Goffman, 1961; Strauss, Schatzman, Burcher, Ehrlich, & Sabshin, 1964). Organizational theorists (Etzioni, 1960; Perrow, 1965) found that state mental hospitals provided rich materials for understanding complex organizational structures and behavior, which led to significant advances in organizational theory. All of the aforementioned studies made significant contributions to sociological understanding of organizational control and power, and mental health care organizations continue to be excellent sites for understanding changing forms of organizational control as well as furthering understanding of conflict between professional and bureaucratic control. As organizational theory developed to include inter-organizational relations and networks of organizations, research on mental health care has contributed to knowledge about how organizations manage contradiction, conflict, and ambiguity (Meyer, 1986; Scott, 1983). Organizational theory also provides a powerful model for understanding changing systems of mental health care (Scheid, 2004; Schlesinger & Gray, 1999).
Journal of Health Care for The Poor and Underserved, 2003
Many researchers have suggested that the implementation of managed care may lower access to, and ... more Many researchers have suggested that the implementation of managed care may lower access to, and quality of, health care services for minorities. However, very little empirical data examining this issue exists. To examine it, the authors used a study design that was both cross-sectional and longitudinal in that they surveyed Medicaid recipients in two counties at two points in time; one of the counties began delivering services through managed care between the two survey periods. Their results indicate that, overall, managed care had neither a positive nor a negative effect on African Americans&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; access to health care services in either absolute terms or relative to whites&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;. In addition, race was not found to be associated with satisfaction. However, a Medicaid recipient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s race was found to negatively affect his or her access to service under both managed care and fee-for-service systems.
Journal of Health Care for The Poor and Underserved, 2003
Many researchers have suggested that the implementation of managed care may lower access to, and ... more Many researchers have suggested that the implementation of managed care may lower access to, and quality of, health care services for minorities. However, very little empirical data examining this issue exists. To examine it, the authors used a study design that was both cross-sectional and longitudinal in that they surveyed Medicaid recipients in two counties at two points in time; one of the counties began delivering services through managed care between the two survey periods. Their results indicate that, overall, managed care had neither a positive nor a negative effect on African Americans&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; access to health care services in either absolute terms or relative to whites&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;. In addition, race was not found to be associated with satisfaction. However, a Medicaid recipient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s race was found to negatively affect his or her access to service under both managed care and fee-for-service systems.
Administration and Policy in Mental Health, 2003
The authors analyzed changes in access to and use of mental health services by minorities in the ... more The authors analyzed changes in access to and use of mental health services by minorities in the Veterans Health Administration during a period of major system change (1995–2001). Blacks had poorer outpatient access than Whites during this period of change, but were not further disadvantaged over time, and their access to care improved relative to Whites on some measures. For Hispanics, there was a trend toward greater inequality in the delivery of outpatient mental health care. These results suggest a need to monitor and address the differential impact on minorities of changes in mental health service delivery.
General Hospital Psychiatry, 2006
Objective: Advanced practice nurses (APNs), including clinical nurse specialists and nurse practi... more Objective: Advanced practice nurses (APNs), including clinical nurse specialists and nurse practitioners, now have prescribing privileges in all states. This study examined the proportion of Department of Veteran Affairs (VA) mental health patients who were seen by any prescribing professional and specifically the proportion and characteristics of patients who were treated exclusively by APNs. Method: Logistic regression models were used to examine data on all patients who received care in VA specialty mental health clinics in 2002 (n = 767,920). We first identified patient characteristics independently associated with prescriber contact and, secondly, among those with prescriber contact, exclusive contact with an APN. We also compared characteristics of patients seen exclusively by an APN with those who saw both a physician and an APN. Results: The strongest predictors of both whether a veteran saw a prescriber (66.6%) and whether that prescriber was exclusively an APN (6.7%) were indicators of severity. Specifically, more severe diagnoses, such as schizophrenia or bipolar disorder, receipt of VA disability payments and greater service use increased the odds that a veteran would have had a prescriber contact, decreased the odds that they would see an APN exclusively and, among those who saw an APN, increased the odds that they would also see a physician. Conclusions: Patients who see physician prescribers have more severe mental health problems than those who see APNs. Our results indicate that APNs and physicians treat distinguishable patient populations, suggesting that APNs may not be substitutes for physicians. D
Journal of Behavioral Health Services & Research, 2003
Continuity of care (COC) has often been viewed as a crucial indicator of treatment quality for pa... more Continuity of care (COC) has often been viewed as a crucial indicator of treatment quality for patients with severe psychiatric or addictive disorders. However, the relationship between COC and clinical outcomes has received little empirical evaluation. This study used hierarchical linear modeling to examine the relationship between six indicators of COC and seven outcome measures addressing symptoms, substance abuse, and social functioning. Patient interviews were conducted with 1576 veterans 3 months after their discharge from one of 22 residential work therapy programs for the treatment of severe substance abuse. Few significant relationships were found between COC and outcome measures in analyses conducted at both the client and program level and fewer than half of these show better outcomes with greater COC. When a Bonferroni corrected P level of P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0012 was used, none of the relationships were statistically significant. Although there were significant relationships between outcomes and measures of services received during residential treatment, postdischarge COC does not seem to be related to improved outcomes, at least when examined following long term intensive residential treatment. Thus, our results are specific to the context of aftercare following long-term residential rehabilitation and indicate that the value of standard performance measures may vary by treatment context.
Criminal Behaviour and Mental Health, 2008
Aims This study sought to investigate the rates and correlates of homelessness (i.e. living on th... more Aims This study sought to investigate the rates and correlates of homelessness (i.e. living on the street or in a homeless shelter), including mental illness, among US adult state and federal prison inmates (ASFPIs).Method Data from a national survey of ASFPIs based on a random sampling survey (N = 17,565) were used to compare the homelessness rate among AFSPIs with that in the general population. Logistic regression was then used to examine the association of homelessness among ASFPIs with factors including symptoms, treatment of mental illness, previous criminal justice involvement, specific crimes, and demographic characteristics.Results Nine percent of ASFPIs reported an episode of homelessness in the year prior to arrest, 4–6 times the estimated rate in the general US adult population after allowing for age, race/ethnicity, and gender. In comparison to other inmates, these homeless inmates were more likely to be currently incarcerated for a property crime, but also to have had previous criminal justice system involvement for both property and violent crimes, to suffer from mental health and/or substance abuse problems, and to be more likely to have been unemployed and with a low income.Conclusions Recent homelessness is far more common among ASFPIs than the general population. Prior incarceration, mental illness, substance abuse and disadvantageous socio-demographic characteristics were all found to be associated with homelessness among prison inmates, suggesting that there are several important factors in addition to efforts to survive with limited resources through criminal acts that influence the rates of homelessness among incarcerated individuals. Published in 2008 by John Wiley & Sons, Ltd.
Administration and Policy in Mental Health, 2010
This study sought to investigate correlates of past homelessness, especially mental illness and s... more This study sought to investigate correlates of past homelessness, especially mental illness and substance abuse, using data from the National epidemiological survey on alcohol and related conditions (NESARC), a large nationally representative survey conducted in 2001–2002. Multivariate analyses showed that the factors most strongly related to past homelessness were diagnoses of behavioral health conditions which showed consistently stronger association than sociodemographic characteristics, measures of economic well being, or general health indicators. The results presented here confirm in a nationally representative sample a number of single site studies that have also demonstrated the over representation of both mental illness and substance abuse disorders in homeless populations.
Administration and Policy in Mental Health, 2004
This study used hierarchical linear models to analyze post-discharge data among 17,130 veterans w... more This study used hierarchical linear models to analyze post-discharge data among 17,130 veterans who received inpatient VA mental health services between 1995 and 2001, in order to determine whether changes in mental health service affected inpatient satisfaction. In models without covariants, half the satisfaction measures increased while the other half indicated no significant change. After adjusting for changes in patient characteristics, however, nine measures indicated no change and seven showed significant declines. Demonstrating the importance of risk-adjustment, satisfaction appeared to increase over time prior to risk adjustment, but declined after adjusting for changes in patient characteristics that were associated with patient satisfaction.
Journal of Health Care for The Poor and Underserved, 2006
This study examines housing status at the time of hospital discharge in a national sample of 3,50... more This study examines housing status at the time of hospital discharge in a national sample of 3,502 veterans who were homeless at admission to a Veterans Health Administration (VHA) medical center. A supplemental survey on homelessness was added to the annual VHA inpatient census over a 4-year period (1995 through 1998). Data from this survey were used to identify homeless veterans hospitalized on the final day of the fiscal year and to document their housing status at discharge. A signal detection technique, Receiver Operating Characteristic analysis, was used to identify predictors of housing status at discharge. At discharge, only 13% of the veterans in our analytic sample were literally homeless, 40% were doubled up, and 33% were transferred to another an institution; only 13% were living independently. Housing status at admission (specifically, staying with friends or family temporarily rather than literally homeless), treatment in a psychiatric or substance abuse program rather than a medical program, and a greater income level or access to VHA benefits were found to be associated with better housing outcomes. As one might expect, homelessness was infrequently resolved during an acute inpatient hospitalization, but few veterans returned to literal homelessness at the time of discharge.
International Journal of Offender Therapy and Comparative Criminology, 2012
Journal of Health Care for The Poor and Underserved, 2010
This study uses data from a nationally representative epidemiologic survey, the National Comorbid... more This study uses data from a nationally representative epidemiologic survey, the National Comorbidity Survey Replication, to investigate the association of mental health and substance use disorders, along with other factors, with past homelessness. Approximately 5% of the 5,251 adults reported having been homelessness. Multivariate analysis showed the strongest independent risk factors for past homelessness were past receipt of welfare payments (odds ratio [OR]=5.7), incarceration for 27 or more days (OR=3.9), exposure to personal violence (OR=2.7), lifetime substance use disorder (OR=2.4), and Black race (OR=2.1). Several non-substance use psychiatric disorders were also significantly, if less strongly (OR 1.4 to 1.6), associated with past homelessness. Past homelessness is associated with a broad array of sociodemographic, economic, and mental health problems. While the association of both substance use and psychiatric disorders with past homelessness was quite strong, non-substance use psychiatric disorders was not as strong an independent risk factor as substance abuse disorders.
Psychiatric Quarterly, 2007
Public support payments may facilitate exit from homelessness for persons with mental illness. We... more Public support payments may facilitate exit from homelessness for persons with mental illness. We examined data from 10,641 homeless veterans contacted from October 1, 1995 to September 30, 2002 in a collaborative outreach program designed to facilitate access to Department of Veterans Affairs (VA) disability benefits. Those who were awarded benefits (22% of contacted veterans) were more likely to report disability, poor to fair self-rated health, and were more likely to have used VA services in the past. Thus, this program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.
Psychiatric Quarterly, 2004
Continuity of care (COC) is often used as an indicator of treatment quality for patients with sev... more Continuity of care (COC) is often used as an indicator of treatment quality for patients with severe psychiatric or addictive disorders. However, few studies have examined the relationship between measures of COC and treatment outcomes. This study used standard regression models to examine the strength of the association between continuity of care measures and health outcomes for a sample of female veterans newly entering outpatient treatment for PTSD. There were few consistently significant associations between COC and outcome measures. Four months following program entry only one measure of treatment process, commitment to treatment, was positively associated with one or more continuity of care measures and several COC measures were associated with poor outcomes. Eight months following program entry patients with greater COC during the first four months of treatment had greater declines in violent behavior and PTSD measurements and larger increases in global functioning. However, when a Bonferonni corrected alpha of P <.001 was used to adjust for multiple comparisons, none of the relationships remained statistically significant. Thus, this study provides only weak and inconsistent evidence of the clinical benefits of continuity of care.
Psychiatric Quarterly, 2006
There has been a growing interest in the implementation of evidence-based specialized mental heal... more There has been a growing interest in the implementation of evidence-based specialized mental health programs. However, there has been little study of the effectiveness of these programs in comparison with standard mental health care in real world mental health systems. This study used a national sample of patients from the Veterans Health Administration to compare changes in mental health status in various specialized mental health outpatient programs and in general psychiatric clinics. Hierarchical linear models were used to compare the association of both regularity and intensity of care in six specialized mental health programs with GAF change scores in patients treated in general psychiatric clinics. While improvements were observed in all programs, two specialized programs performed better overall than general psychiatric care, one was not significantly different, and three had poorer outcomes than general psychiatric clinics. Programmatic differences in target populations accompanied by imperfect risk adjustment for population differences most likely explain why these results differ from those observed in clinical trials. While the analytic strategies demonstrated here may have wider applicability to comparative performance assessment, this study provides a cautionary tale concerning the limits of conclusions that can be drawn from large scale outcomes monitoring efforts.
Journal of Behavioral Health Services & Research, 2003
Evaluation of the quality of outpatient treatment for patients with severe psychiatric or addicti... more Evaluation of the quality of outpatient treatment for patients with severe psychiatric or addictive disorders has often focused on the assessment of continuity of care (COC) as measured with administrative data. However, there has been little empirical evaluation of the relationship of measures of COC and treatment outcomes. This study used hierarchical linear modeling to examine the relationship between 6 indicators of COC and 6 outcome measures in a multisite monitoring effort for veterans with war-related posttraumatic stress disorder. There were few consistently significant associations between COC and outcome measures. Although measures of COC at the level of individual patients were associated with reductions in substance abuse symptoms, when COC measures were averaged to the site level and examined with hierarchical linear modeling models, thereby reducing the impact of intrasite selection bias, they were not associated with any desired outcomes. COC measures, at least in the sample used for this study, are not consistently associated with desirable client outcomes and may therefore be less than ideal performance measures in outcome evaluations following inpatient treatment, except to the extent that COC is considered to be an intrinsic indicator of higher quality regardless of its relationship to outcomes.
Psychiatric Quarterly, 2009
Data derived from the 2002 Survey of Inmates in Local Jails and the 2000 National Survey of Veter... more Data derived from the 2002 Survey of Inmates in Local Jails and the 2000 National Survey of Veterans show that having mental health problems in addition to such sociodemographic characteristics as being a member of a minority group, not being married, having less education, and being younger are risk factors for incarceration among veterans, as they are for the general population. As in previous studies veterans who served during the Vietnam Era and to an even greater extent, those who served in the early years of the All Volunteer Force were at greater risk of incarceration than veterans from the most recent period of the AVF, after controlling for age and other factors.
Medical Care, 2003
To investigate the impact of implementing service line organization on the delivery of mental hea... more To investigate the impact of implementing service line organization on the delivery of mental health services. Survey data on the implementation of service lines and facility-level administrative data on the delivery of mental health services at 139 Department of Veterans Affairs medical centers (VAMCs), over a 6-year period, were used to examine the relationship between service line implementation and subsequent performance in 4 areas: 1) continuity of care (COC), 2) readmission after inpatient discharge, 3) emphasis on community-based mental health care (as contrasted with inpatient care), and 4) maintenance of proportionate funding for mental health care. Models were analyzed using hierarchical linear modeling techniques to control for potential autocorrelation. Of 6 COC measures, 1 strongly improved in all years following service line implementation, and 3 of the 5 other measures demonstrated improvement in the first year. One of 2 readmission measures showed a decline in the first year after service line implementation. Service line implementation was associated with only 1 indicator of increased emphasis on community-based mental health care (and only in the first year), whereas 3 of the 4 other measures suggested a decline in such emphasis. Lastly, although there were increases in per capita mental health expenditures 3 or more years after service line implementation, 2 related measures indicated that service line implementation was associated with a decline in mental health expenditures relative to nonmental health services. Service line implementation was associated with significant, although predominantly short-term, improvement in patient level variables such as continuity of care and hospital readmission, but less so with regard to institutional measures addressing emphasis on outpatient care and maintaining proportionate funding of mental health services.