Service utilization and cost of community care for discharged state hospital patients: a 3-year follow-up study.

OBJECTIVE: This study examined the mental health service utilization and costs of 321 discharged state hospital patients during a 3-year follow-up period compared with costs if the patients had remained in the hospital. METHOD: The study subjects were long-stay patients discharged from Philadelphia State Hospital after 1988. A longitudinal integrated database on all mental health and medical services reimbursed by Medicaid and Medicare as well as state- and county-funded services was used to construct service utilization and unit cost measures. RESULTS: During the 3-year period after discharge, 20%-30% of the patients required rehospitalization an average of 76-91 days per year. The percentage of rehospitalized patients decreased over time, but the number of hospital days increased. All of the discharged patients received case management services, and a majority also received outpatient mental health care (66%-70%) and residential services (75%) throughout the follow-up period. The total treatment cost per person was approximately $60,000 a year after controlling for inflation, with costs rising slightly over the 3-year period. The estimated cost of state hospitalization, with the use of 1992 estimates, would have been $130,000 per year if the patients had remained institutionalized. CONCLUSIONS: This analysis suggests that most former long-stay patients are able to live in residential settings while receiving community outpatient treatment and intensive case management services at a reduced cost. There is no indication of cost shifting from the psychiatric to the health care sector; however, some cost shifting from the state mental health agency to the Medicaid program has occurred, since most psychiatric hospital care now takes place in community hospitals.     

Homelessness among persons with serious mental illness in an enhanced community-based mental health system

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.     

Cost and cost-effectiveness of hospital vs residential crisis care for patients who have serious mental illness

BACKGROUND: This study evaluates the cost and cost-effectiveness of a residential crisis program compared with treatment received in a general hospital psychiatric unit for patients who have serious mental illness in need of hospital-level care and who are willing to accept voluntary treatment. METHODS: Patients in the Montgomery County, Maryland, public mental health system (N = 119) willing to accept voluntary acute care were randomized to the psychiatric ward of a general hospital or a residential crisis program. Unit costs and service utilization data were used to estimate episode and 6-month treatment costs from the perspective of government payors. Episodic symptom reduction and days residing in the community over the 6 months after the episode were chosen to represent effectiveness. RESULTS: Mean (SD) acute treatment episode costs was $3046 ($2124) in the residential crisis program, 44% lower than the $5549 ($3668) episode cost for the general hospital. Total 6-month treatment costs for patients assigned to the 2 programs were $19,941 ($19,282) and $25,737 ($21,835), respectively. Treatment groups did not differ significantly in symptom improvement or community days achieved. Incremental cost-effectiveness ratios indicate that in most cases, the residential crisis program provides near-equivalent effectiveness for significantly less cost. CONCLUSIONS: Residential crisis programs may be a cost-effective approach to providing acute care to patients who have serious mental illness and who are willing to accept voluntary treatment. Where resources are scarce, access to needed acute care might be extended using a mix of hospital, community-based residential crisis, and community support services.     

The impact of closing a state psychiatric hospital on the county mental health system and its clients.

OBJECTIVE: This three-year study examined the impact of closing a state psychiatric hospital in 1991 on service utilization patterns and related costs for clients with and without serious mental illness. METHODS: The cohort consisted of all individuals discharged from state hospitals and those diverted from inpatient to community services and enrolled in the unified systems project, a state-county initiative to build up the service capacity of the community system. The size of the cohort grew from 1,533 enrollees to 2,240 over the three years. Information on the types, amounts, and cost of all services received by each enrollee was compiled from multiple administrative databases, beginning two years before enrollment and for up to three years after. The data were analyzed to reveal patterns of and changes in service utilization and related costs. RESULTS: Replacement of most inpatient services with residential and ambulatory services resulted in significant cost reduction. For project enrollees, a 94 percent reduction in state hospital services resulted in cost savings of more than $45 million during the three-year evaluation period. These savings more than offset the funds used to expand community services. Overall, the net savings to the system for mental health services for this group was $3.4 million over three years. CONCLUSIONS: The hospital closure and infusion of funds into community services produced desired growth of those services. The project reduced reliance on state psychiatric hospitalization and demonstrated that persons with serious mental illness can be effectively treated and maintained in the community.     

Service use and outcomes of first-admission patients with psychotic disorders in the Suffolk County Mental Health Project

OBJECTIVE: The purpose of the study was to examine the inpatient and outpatient service use and 4-year outcomes of newly admitted psychotic patients during a period of rapid change in the provision of psychiatric services in a well-defined catchment area in New York State in the 1990s. METHOD: Subjects were 573 participants of the Suffolk County Mental Health Project. This group comprised patients with psychotic disorders first admitted between September 1989 and August 1995 to 12 inpatient facilities across Suffolk County, N.Y., and followed for up to 48 months. The subjects' service use, course of illness, symptomatic outcomes, suicide risk, homelessness risk, and satisfaction with care were compared across admission years. RESULTS: The length of inpatient stays decreased significantly across the years. However, the number of outpatient visits and therapy sessions did not vary. Although the patients admitted in later years were more symptomatic at admission to their first hospitalization, their course and outcomes over the follow-up period were not worse and they were not less satisfied with their care, compared with the patients admitted in earlier years. CONCLUSIONS: The clinical characteristics of patients and the role of inpatient care in the management of patients with psychotic disorders gradually changed during the 1990s. These changes, however, were not associated with changes in the use of outpatient services or outcomes. Nevertheless, shorter hospital stays and the presence of more severely ill patients highlight the need for more attention to linkage to aftercare and enhancement of support networks in the community.     

Childhood antecedents of homelessness in psychiatric patients

OBJECTIVE: This study examined the relationship between childhood experience and homelessness in psychiatric patients. METHOD: Three large and diverse samples of homeless patients (N = 512) were compared with a sample of patients who had never been homeless (N = 271), with respect to childhood experience of foster care, group home placement, and running away. One of the homeless samples and the never homeless sample were drawn from patients admitted to a state mental hospital. In this state hospital population, risk ratios for lifetime prevalence of homelessness could be derived. RESULTS: In the three homeless samples, over 15% had a history of foster care, over 10% had a history of group home placement, and over 20% had a history of running away. These figures compared with 2%, 1%, and 5%, respectively, in the never homeless sample. In the state hospital, the lifetime prevalence of homelessness in patients with any one of these childhood experiences was about threefold that of other patients. A history of homelessness was reported by the great majority of state hospital patients who had had one of these childhood experiences. CONCLUSIONS: These childhood experiences were strongly associated with adult homelessness in these psychiatric patients. It might be possible to prevent homelessness in some cases by interventions aimed at patients with such childhood histories.     

Post-discharge Contact with Mental Health Clinics and Psychiatric Readmission: A 6-month Follow-up Study

Background: Continuity of mental health care is a major topic in the post deinstitutionalization era, especially concerning its possible importance as a contributing factor in preventing rehospitalization. Objectives: To examine a) the association between continuing care and time to rehospitalization; and b) the predictors of time to first outpatient contact after discharge from psychiatric hospital. Methods: Hospitalization records of all patients discharged from the Tirat Carmel psychiatric hospital in Israel, between January 1, 2006, and December 31, 2006, the National Register of Psychiatric Hospitalizations database and administrative databases of all psychiatric outpatient clinics in this catchment area were used to monitor continuing care and rehospitalization within 180 days from discharge. Predictors of time to rehospitalization and outpatient visits were examined using a Cox proportional hazards regression model. Results: Out of the 908 discharged inpatients, 29% were rehospitalized and 59% visited an outpatient clinic during the study period. Of those who visited a clinic, 22% were rehospitalized compared with 40% of those who did not visit. Not making aftercare contact with a mental health clinic during the study period and/ or having a history of more than four hospitalizations were significant predictors of earlier psychiatric readmission. Males and patients diagnosed with schizophrenia or affective disorders made contact with outpatient clinics significantly earlier. Patients who were discharged from the hospital after a daycare period contacted outpatient clinics significantly later than those who were not in daycare. Conclusions: The findings suggest that psychiatric rehospitalization is associated with discontinuity of contact with psychiatric services but not with diagnosis. Patients with schizophrenia or affective disorders were found to adhere to a greater degree to clinical aftercare, which may explain why they are not rehospitalized earlier than less severe patients.     

Downsizing psychiatric hospitals: needs for care and services of current and discharged long-stay inpatients.

BACKGROUND: With the psychiatric deinstitutionalization movement in its fourth decade, questions are being raised concerning its relevance for long-stay inpatients with severe disabilities and the risk that those discharged into the community may be abandoned. METHODS: A random sample taken in 1989 of long-stay inpatients at Louis-H Lafontaine Hospital made it possible to examine 96 pairs of patients. Each pair included 1 patient discharged between 1989 and 1998 and 1 patient hospitalized. Pairs were matched for sex, age, length of stay, and level of psychiatric care in 1989. Patients and staff were interviewed using standardized questionnaires, and case notes were reviewed to assess symptoms, daily living skills, residential status, quality of residential setting, and clinical and social problems and needs. RESULTS: The investigation revealed that discharged patients moved to highly supervised settings, which included professionally supervised group homes, supervised hostels, and foster families. About 20% went to nursing homes owing to loss of autonomy from physical disorders. Only 4 discharged patients were lost to follow-up, of whom 2 were probable vagrants. Both those discharged and those remaining as inpatients presented with major clinical problems and daily living skill deficits. The care needs of discharged patients were generally met, and placement in the community was considered appropriate. Of those who had remained hospitalized, over one-half could be moved to supervised settings immediately, or after 1 to 2 years' preparation in a discharge unit, while 13% could be moved to nursing homes. Over 25% required intensive, individualized rehabilitation treatment targeting engagement, psychotic symptoms, withdrawal, and dangerous and socially embarrassing behaviours. CONCLUSION: Deinstitutionalization in the largest Canadian psychiatric hospital did not lead to patient abandonment in the community.     

Medicare Inpatient Treatment for Elderly Non-dementia Psychiatric Illnesses 1992–2002; Length of Stay and Expenditures by Facility Type

We summarize Medicare utilization and payment for inpatient treatment of non-dementia psychiatric illnesses (NDPI) among the elderly during 1992 and 2002. From 1992 to 2002, overall mean Medicare expenditures per elderly NDPI inpatient stay declined by $2,254 (in 2002 dollars) and covered days by 2.8. However, these changes are complicated by expanded use of skilled nursing facilities and hospital psychiatric units, and decreased use of long-stay hospitals and general hospital beds. This suggests that inpatient treatment for NDPI is shifting into less expensive settings which may reflect cost-cutting strategies, preferences for less restrictive settings, and outpatient treatment advances.     

Risk factors for homelessness in adolescents released from psychiatric residential treatment

OBJECTIVES: To measure the incidence of homelessness among youths discharged from an inpatient facility as well as to identify factors that place these youths at risk for homelessness. METHOD: Reports of homelessness during 5 years of follow-up interviews with 83 adolescents consecutively discharged from an inpatient facility were used in conjunction with chart reviews. RESULTS: One third of youths experienced at least one homeless episode after discharge. Youths who had a history of substance use, physical abuse, running away, or being in state custody were more likely to become homeless than those without such factors. Having a thought disorder, however, was inversely related to becoming homeless after hospital discharge. CONCLUSIONS: Youths discharged from a residential treatment facility are at high risk for becoming homeless. Interventions to prevent homelessness among adolescent inpatients should be targeted to those with a history of substance abuse, physical abuse, running away, and being in state custody.     

Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients

OBJECTIVE: The authors hypothesized that psychiatric liaison screening of elderly patients with hip fractures would shorten the average length of hospital stay and increase the proportion of patients who returned home after discharge. METHOD: The study was performed at Mount Sinai Medical Center in New York and Northwestern Memorial Hospital in Chicago. The subjects were 452 patients 65 years or older who were consecutively admitted for surgical repair of fractured hips. During a baseline year the patients received traditional referral for psychiatric consultation. During the experimental year all the patients at Mount Sinai and the patients on one Northwestern Unit were screened for psychiatric consultation. RESULTS: The patients who received psychiatric liaison screening had a higher consultation rate than those who received traditional consultation. The rates of DSM-III disorders in the experimental year were 56% at Mount Sinai and 60% at Northwestern. The mean length of stay was reduced from 20.7 to 18.5 days at Mount Sinai and from 15.5 to 13.8 days at Northwestern, resulting in reductions in hospital costs ($647/day) of $166,926 and $97,361, respectively. Fees generated from Medicare service delivery could have paid for the $20,000 psychiatric intervention cost at each site. There was no difference, however, between the two years in the discharge placement of patients. CONCLUSIONS: Admission psychiatric liaison screening of elderly patients with hip fractures results in early detection of psychiatric morbidity, better psychiatric care, earlier discharge, and substantial cost savings to the hospital.     

Deinstitutionalisation for long-term mental illness: cost differences in hospital and community care

OBJECTIVE: This project studied the cost analysis of psychiatric hospital and then community care for long-stay patients with chronic mental illness discharged during the closure of a psychiatric hospital in Sydney. METHOD: Expenditure and income data in both settings were collected. Costs were analysed on an occupied bed-day basis. RESULTS: The hospital setting cost more per patient per day compared with the various community costs which were one-third to one-half of the comparable hospital costs. CONCLUSIONS: The analysis demonstrated overall that hospital care was nearly twice as expensive as care in the community setting. The factors which may have influenced, although not necessarily altered, the substance of the findings largely related to 'organisational efficiency'. The mental hospital as an older, more rigid system was likely to be less efficient than the newer community service provision which was under intensive scrutiny both clinically and financially by all interested parties.     

Estimating the capital component of mental health care costs in the public sector

This study describes methods for determining the cost of buildings and grounds in public sector facilities. Two methods for estimating the cost of capital (one using local office rents; the other based on estimates of the replacement cost of hospital buildings) are applied to six types of health care service at nine VA medical centers. Results indicate that capital costs for psychiatric inpatient care were about one-third those for surgical services and one-half those for medical services. Overall, capital costs and 6% to average inpatient costs and 4% to outpatient costs.     

Shifting to outpatient care? Mental health care use and cost under private insurance.

OBJECTIVE: Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care. METHOD: Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized. RESULTS: Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%). CONCLUSIONS: Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.     

Schizophrenic patients in different treatment settings during the era of deinstitutionalization: three-year follow-up of three discharge cohorts in Finland

OBJECTIVE: We investigated differences in psychosocial and clinical characteristics, as well as the use of services, of schizophrenic patients in different treatment settings three years after their discharge from a psychiatric hospital. Furthermore, we examined secular changes in these phenomena during the era of rapid deinstitutionalization in Finland. METHOD: Three nationally representative samples comprised 3257 schizophrenic patients who had been discharged in 1986, 1990 and 1994. The patients were interviewed three years after discharge by each district's psychiatric professionals using a structured interview schedule specifically designed for the purposes of the present study. Psychosocial functioning was assessed on the Global Assessment Scale and on a modified version of the Medical Research Council Practices Profile. RESULTS: In the 1990s, more patients with a poor clinical and psychosocial state were transferred from hospital to alternative outpatient facilities, such as sheltered workshops or supported residences. In successive cohorts, the proportion of patients who had dropped out of treatment decreased and the psychiatric and somatic state of the drop-outs improved. CONCLUSION: In general, the psychiatric treatment system has worked well for most deinstitutionalized patients. In the future, however, it is important that the quality of care and adequate resources in the alternative outpatient facilities are ensured.     

Economic analysis of an epilepsy outreach model of care in a university hospital setting

The prevalence of epilepsy in people with intellectual disability is higher than in the general population and prevalence rates increase with increasing levels of disability. Prevalence rates of epilepsy are highest among those living in residential care. The healthcare needs of people with intellectual disability and epilepsy are complex and deserve special consideration in terms of healthcare provision and access to specialist epilepsy clinics, which are usually held in acute hospital campuses. This patient population is at risk of suboptimal care because of significant difficulties accessing specialist epilepsy care which is typically delivered in the environs of acute hospitals. In 2014, the epilepsy service at Cork University Hospital established an Epilepsy Outreach Service providing regular, ambulatory outpatient follow up at residential care facilities in Cork city and county in an effort to improve access to care, reduce the burden and expense of patient and carer travel to hospital outpatient appointments, and to provide a dedicated specialist phone service for epilepsy related queries in order to reduce emergency room visits when possible. We present the findings of an economic analysis of the outreach service model of care compared to the traditional hospital outpatient service and demonstrate significant cost savings and improved access to care with this model. Ideally these cost savings should be used to develop novel ways to enhance epilepsy care for persons with disability. We propose that this model of care can be more suitable for persons with disability living in residential care who are at risk of losing access to specialist epilepsy care.     

Clinical management for hospital-treated deliberate self-poisoning: comparisons between patients with major depression and borderline personality disorder

OBJECTIVE: To compare the initial clinical management of hospital-treated deliberate self-poisoning patients with major depressive disorder (MDD) or borderline personality disorder (BPD) after controlling for demographic factors and level of suicide ideation. METHOD: This study compared sequential hospital treated deliberate self-poisoning patients (n = 570) with either MDD or BPD (but no major comorbid psychopathology) on four outcomes modelled using logistic regression: (i) length of stay in the general hospital; (ii) discharge to a psychiatric hospital; (iii) psychiatric follow-up; and (iv) general practitioner (GP) follow-up. RESULTS: BPD and MDD patients were discharged to psychiatric inpatient care at very similar rates (33%-35%) and almost all subjects with high levels of suicidal ideation were discharged to psychiatric hospital. However, for mild to moderate levels of suicidal ideation BPD patients were more likely to be discharged to psychiatric hospital than MDD patients. After controlling for demographics and suicidal ideation, BPD patients were more likely to be referred for psychiatric hospitalization on discharge (adjusted OR = 1.79, 95% CI = 1.01-3.18) and less likely to be referred to GPs if discharged to home (adjusted OR = 0.44, 95% CI = 0.24-0.81). There were no differences in general hospital length of stay or arrangements made for psychiatric follow-up for those discharged to home. CONCLUSIONS: This suggests that for mild to moderate suicidal ideation levels clinicians are more likely to choose to send BPD patients, after deliberate self-poisoning, to inpatient psychiatric care than MDD patients. Clinicians are also apparently more likely to choose to manage MDD patients in primary care settings, for those patients discharged to home. This has implications for service planning and clinical guidelines.     

Psychiatric treatment in a delimited population-with particular reference to outpatients. A demographic study.

The present investigation analyses the psychiatric service available to and utilized by a population in a geogrphically delimited area, namely the Randers area with a population of 108.928. During the period 1970-74, the average yearly rate of patients admitted to the three psychiatric institutions covering this area was per 1,000: 7.9 males and 9.1 females. During 1970-71, 1.2 males and 1.8 females per 1,000 were treated as outpatients in a psychiatric clinic affiliated to a psychiatric hospital, and a psychiatric outpatient clinic in a general hospital discharged 4.1 males and 7.7 females per 1,000. It seems probable that despite outpatient treatment the number of admissions increases slightly rather than decreases, and consequently, outpatient treatment cannot replace psychiatric admission.     

Psychiatric service use: a cohort study of first attenders.

A retrospective cohort study was undertaken of all 1047 first-ever psychiatric service attenders to Christchurch general psychiatric services in 1981. All episodes of care were examined to the end of 1989. Only 24% of contacts were as an inpatient. Long-term contacts and frequent presenters formed only 15% of the sample. Nearly all cases not immediately discharged remained within the adult general service. Demographic and clinical variables and patterns of resource use are discussed.