Factors predicting choice of provider among homeless veterans with mental illness

OBJECTIVE: Homeless persons with serious mental illness are especially likely to lack access to comprehensive medical and psychiatric care. This study examined the relative importance of predisposing factors, illness factors, and enabling factors as determinants of the use of Veterans Affairs (VA) health care services by mentally ill homeless veterans seeking services from a non-VA program. Predisposing factors included demographic characteristics and wartime service; illness factors were related to the type of medical problem and the need to seek medical care; and enabling factors included entitlement to VA medical services and location of VA facilities. METHODS: Logistic regression analysis was used to analyze data for 698 homeless veterans with mental illness who were enrolled in the Access to Community Care and Effective Services and Supports (ACCESS) program. RESULTS: About 56 percent of the mentally ill homeless veterans had used VA services at some time in their lives. Homeless veterans were almost twice as likely as other poor veterans to use VA services; those with a dual diagnosis were also more likely to use VA services. Enabling factors were more important than either predisposing or illness factors in predicting VA service use. Veterans most likely to use VA services were those who received VA benefits that gave them priority access to VA services and those who lived near a VA medical center. CONCLUSIONS: Specific characteristics of the service system and of veterans' entitlement were more important than clinical needs or predisposing factors in predicting service use.     

Effects of an outreach intervention on use of mental health services by veterans with posttraumatic stress disorder

OBJECTIVE: The study examined the effectiveness of an outreach intervention designed to increase access to mental health treatment among veterans disabled by chronic posttraumatic stress disorder (PTSD) and identified patient-reported barriers to care associated with failure to seek the treatment offered. METHODS: Participants were 594 male Vietnam veterans who were not enrolled in mental health care at a Department of Veterans Affairs (VA) medical center but who were receiving VA disability benefits for PTSD. Half the sample was randomly assigned to an outreach intervention, and the other half was assigned to a control group. Veterans in the intervention group received a mailing that included a brochure describing PTSD treatment available at an urban VA medical center, along with a letter informing them about how to access care. Participants in the intervention group were subsequently telephoned by a study coordinator who encouraged them to enroll in PTSD treatment and who administered a survey assessing barriers to care. RESULTS: Veterans in the intervention group were significantly more likely than those in the control group to schedule an intake appointment (28 percent versus 7 percent), attend the intake (23 percent versus 7 percent), and enroll in treatment (19 percent versus 6 percent). Several patient-identified barriers were associated with failure to seek VA mental health care, such as personal obligations that prevented clinic attendance, inconvenient clinic hours, and current receipt of mental health treatment from a non-VA provider. CONCLUSIONS: Utilization of mental health services among underserved veterans with PTSD can be increased by an inexpensive outreach intervention, which may be useful with other chronically mentally ill populations.     

Locus of mental health treatment in an integrated service system

OBJECTIVE: Epidemiological surveys suggest that half of mental disorders in the community are treated in general medical settings. This paper examines delivery of mental health services in psychiatric, primary care, and specialty medical clinics in the Department of Veterans Affairs (VA), the largest integrated public-sector health care system in the United States. METHODS: The study examined all outpatient visits to VA clinics between October 1996 and March 1998, a time during which VA policy promoted a shift to a primary care model. For veterans with a primary diagnosis of a mental or substance use disorder who made any visit to a VA psychiatric, primary care, or specialty medical clinic, we compared the locus of care and case mix as well as changes in treatment patterns during the study period. RESULTS: Of 437,035 veterans treated for a mental disorder during the final six months of the study period, only 7 percent were seen for their mental disorders exclusively in primary care and specialty medical clinics. Compared with veterans with mental disorders treated in specialty mental health clinics, those treated in medical clinics had less serious psychiatric diagnoses and made fewer visits. While there was a substantial shift of care from specialty to primary care during the study period, no comparable change in the distribution of care between medical and mental health settings was found. CONCLUSIONS: Treatment patterns in VA clinics differ markedly from those in the private sector. Research is needed to determine whether and how staffing models developed in HMOs and community samples should be extended to these public-sector settings.     

Mental illness as a predictor of satisfaction with inpatient care at Veterans Affairs hospitals.

OBJECTIVE: Patient satisfaction ratings are increasingly being used as an indicator of quality of care. However, satisfaction scores do not account for differences in satisfaction among patients that may be attributable to sociodemographic characteristics or type of illness rather than to the quality of service delivery. This study examines the role of psychiatric diagnosis in satisfaction with inpatient care delivered at Department of Veterans Affairs (VA) hospitals. METHODS: Data were taken from a large national VA customer feedback survey of patients discharged from VA hospitals between June 1 and August 31, 1995 (N=38,789). Analyses examined whether patients discharged with a psychiatric diagnosis were less satisfied with care than those discharged with a nonpsychiatric diagnosis. RESULTS: Patients with a psychiatric diagnosis were less satisfied with their care, regardless of whether they were treated in a psychiatric treatment program or a medical unit, and this relationship remained after the analysis adjusted for other determinants of satisfaction. The association between low satisfaction and psychiatric diagnosis was more pronounced among nonblack patients. CONCLUSIONS: The results suggest the need for caution in using patient satisfaction measures to compare mental health programs and other health care programs.     

Integrated medical care for patients with serious psychiatric illness: a randomized trial.

BACKGROUND: This randomized trial evaluated an integrated model of primary medical care for a cohort of patients with serious mental disorders. METHODS: A total of 120 individuals enrolled in a Veterans Affairs (VA) mental health clinic were randomized to receive primary medical care through an integrated care initiative located in the mental health clinic (n = 59) or through the VA general medicine clinic (n = 61). Veterans who obtained care in the integrated care clinic received on-site primary care and case management that emphasized preventive medical care, patient education, and close collaboration with mental health providers to improve access to and continuity of care. Analyses compared health process (use of medical services, quality of care, and satisfaction) and outcomes (health and mental health status and costs) between the groups in the year after randomization. RESULTS: Patients treated in the integrated care clinic were significantly more likely to have made a primary care visit and had a greater mean number of primary care visits than those in the usual care group. They were more likely to have received 15 of the 17 preventive measures outlined in clinical practice guidelines. Patients assigned to the integrated care clinic had a significantly greater improvement in health as measured by the physical component summary score of the 36-Item Short-Form Health Survey than patients assigned to the general medicine clinic (4.7 points vs -0.3 points, P<.001). There were no significant differences between the 2 groups in any of the measures of mental health symptoms or in total health care costs. CONCLUSION: On-site, integrated primary care was associated with improved quality and outcomes of medical care.     

Benchmarking treatment of schizophrenia: a comparison of service delivery by the national government and by state and local providers

This study compared treatment of schizophrenia in two types of organization: a national, government-operated health care system, the Department of Veterans Affairs (VA), and in hospitals and clinics operated by state and local providers. Between 1994 and 1996, 746 male patients with a clinical diagnosis of schizophrenia residing in two states in the Southeast and Midwest were surveyed: 192 VA inpatients were compared with 96 non-VA inpatients, and 274 VA outpatients were compared with 184 non-VA outpatients. VA patients were older and had higher incomes than non-VA patients but did not differ significantly on measures of clinical status, satisfaction with providers, or community adjustment. VA outpatients were more likely to have been hospitalized during the previous year than non-VA outpatients and were less likely to have received services from a day hospital, from a case manager or social worker, or to have received crisis intervention services. On 5 of 26 Schizophrenic Patient Outcomes Research Team treatment recommendations, a smaller proportion of VA than non-VA patients adhered to standards. Four of these reflected reduced access among VA patients to psychosocial services such as work therapy, job training, or case management services. Cross-sectional surveys can be used to compare quality of care across service systems. VA care was associated with similar satisfaction and clinical outcomes but greater reliance on hospital treatment and less use of community-based psychosocial services.     

Use of general medical services by VA patients with psychiatric disorders

OBJECTIVE: Patients with psychiatric disorders, particularly those with severe mental illnesses, have high rates of undetected and untreated medical problems and substantially elevated mortality rates due to medical illness. The authors sought to develop a better understanding of the demographic, medical, and psychiatric characteristics of this population to inform efforts to improve the medical care of these persons. METHODS: Using Department of Veterans Affairs (VA) databases, the authors examined use of medical services by 175,653 patients who were treated in Southern California and Nevada during fiscal year 2000. Multivariate regression models were used to examine factors affecting receipt of any medical care and the number of medical visits. RESULTS: Patients with psychiatric diagnoses had fewer medical visits than other VA patients; the largest differences were seen for patients with severe mental illnesses. Patients who were younger and male had few visits. Patients with diabetes or hypertension who had been diagnosed as having schizophrenia, bipolar disorder, or an anxiety disorder had substantially fewer visits than those who did not have these psychiatric diagnoses. Patients older than 50 years were less likely to have any medical care if they had a diagnosis of a substance use, depressive, bipolar, or anxiety disorder or posttraumatic stress disorder. CONCLUSIONS: Use of medical care varies by psychiatric diagnosis. Young adults with schizophrenia and posttraumatic stress disorder and adults of all ages with bipolar disorder have an especially high risk of not receiving general medical services. Interventions to improve medical care may need to be tailored to the population being targeted.     

Depression screening in a VA primary care clinic

In 1998 the U.S. Department of Veterans Affairs (VA) mandated annual depression screening at all VA primary care clinics. The VA Medical Center, New Orleans, implemented a four-item screening tool. The authors report on an evaluation of the screening program. Of 1,100 patients visiting the clinic during a one-month period, 1,068 (97 percent) were screened at that visit or at some point in the previous 12 months. Of the 70 patients who screened positive for depression, 50 (71 percent) were offered at least one treatment modality or psychiatric referral. The findings establish benchmarks for screening administration and for follow-through on positive screens. The authors describe features of the electronic medical record that contributed to the successful implementation of this best practice.     

Current trends in outpatient pharmacy in VA specialized mental health treatment

This report examines current trends in specialized mental health care in the U.S. Department of Veterans Affairs (VA). Over the period 1999 to 2002, inpatient bed-days declined steadily, and the number of outpatient visits increased. Outpatient pharmacy spending increased by nearly 19 percent per year, whereas spending for inpatient, residential, and outpatient nonpharmacy services increased by less than 1.5 percent per year. Total per capita spending declined from 3,262 to 3,061 US dollars as the number of patients served increased faster than did total spending. These trends most likely reflect VA policy changes and the impact of new psychiatric medications.     

The Effects of Federal Versus State Funding and Academic Affiliation on Mental Health Services

This study compares mental health services in three facilities on two domains: federal versus state funding and academic affiliation. Data from a cross-sectional study of psychiatric outpatients is utilized to compare 196 VA patients to 337 non-VA patients treated in two state mental health agencies. The strength of academic affiliation of the facilities and the degree of participation in research and training activities differs significantly across facilities but is not associated with quality of care, clinical outcomes, or satisfaction with care. Compliance with schizophrenia PORT treatment recommendations is low but similar across sites. These findings suggest that, unlike findings from the general medical literature, academic affiliation is unrelated to the quality and delivery of mental health care.This study was supported by VA HSR & D grant #PR94-002. The authors would like to thank the clinical managers at each of the non-VA sites for their help in collecting and interpreting the data, including Jeanne Steiner, D.O. (Connecticut Mental Health Center), and Stephen Atkins, M.D. (Greater Bridgeport Mental Health Center).     

Length of time spent in seclusion and restraint by patients at 82 VA medical centers.

Analysis of data from 82 Veterans Affairs medical centers showed that during a one-year period in 1987-88, VA psychiatric inpatients spent about 240,000 hours in seclusion or restraint, with about half of that time in mechanical restraints. The median length of time patients in each medical center spent in seclusion and restraint was used to classify centers as having "higher" or "usual" rates of use of those techniques. In the 20 centers classified as higher users, patients spent two to three times longer in seclusion and restraint per incident than patients in the 62 centers classified as usual users. Time spent by patients in seclusion and restraint in centers with usual rates of use was consistent with reports from other U.S. studies. The longer time in seclusion and restraint per incident in higher-user centers may be due to characteristics of the medical center or of the patient population.     

Management of Mental Disorders in VA Primary Care Practices

The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.     

The Quality of VA Mental Health Services

This study examines whether male and female veterans differ on either subjective or objective measures of the quality of VA mental health care. The study sample were all discharged with a psychiatric diagnosis from a VA inpatient mental health program. Results indicate that women were less satisfied with inpatient care, but were mixed on their satisfaction with overall mental health care. Males and females did not differ on the quality of inpatient care, but women had significantly higher quality of outpatient care. These results not only highlight the need to stratify or adjust quality measures by gender, but also highlight the potential confounding effect of sub-group specific health behaviors on measures of quality.     

Psychiatric inpatient care in the VA: before, during, and after DRG-based budgeting

OBJECTIVE: The authors examined the impact of budgeting based on diagnosis-related groups (DRGs) on inpatient psychiatric care in Department of Veterans Affairs (VA) medical centers. DRG-based budgeting was implemented by the VA in 1984 and suspended in 1988. METHOD: Computerized discharge abstracts were obtained for all episodes of VA inpatient care occurring from 1980 through 1989. The number of discharges per year, number of unduplicated patients treated, mean length of stay, total number of bed days of care per unique patient per year, readmission rates, and number of episodes of care per operational bed were determined for psychiatric and nonpsychiatric (medical-surgical) hospitalizations occurring before, during, and after DRG-based budgeting was in effect. RESULTS: In the case of VA psychiatric care, DRG-based budgeting was associated with more episodes of care, shorter lengths of stay, higher readmission rates, and more episodes of care per occupied bed. DRG-based budgeting had similar effects on medical-surgical care, although an increase in the number of episodes of care was not observed. During the first year after this funding mechanism was suspended, changes in both psychiatric and medical-surgical care that were related to DRG-based budgeting were slowed and, in some cases, reversed. CONCLUSIONS: Both psychiatric and medical-surgical inpatient care in the VA were sensitive to changes in funding mechanisms. These changes were generally similar to those observed in psychiatric care provided by non-VA hospitals reimbursed under Medicare's DRG-based prospective payment system.     

Treatable comorbid conditions and use of VA health care services among patients with dementia

OBJECTIVE: Although dementia is a progressive degenerative disease, treatable comorbid symptoms, such as pain, aggression, depression, and psychosis, occur among more than 60 percent of patients with dementia. Compared with age-matched controls, patients with dementia use 70 percent more health services and account for 50 percent more managed care costs. This prospective study examined the longitudinal relationship between use of health care services and treatable comorbid conditions among patients with dementia. METHODS: Ninety-nine patient-caregiver dyads from the Michael E. DeBakey Veterans Affairs (VA) Medical Center in Houston, Texas, completed a one-time interview. Patients' VA records were reviewed one year later to examine the relationships between the study variables and three types of service use: inpatient medical stays, outpatient medical visits, and outpatient psychiatric visits. RESULTS: Pain was positively associated with all types of service use. Depression was associated with outpatient psychiatric visits. Psychosis and aggression were not significantly associated with future use of health care services. CONCLUSIONS: The results of this study confirm previous findings that pain and depression are associated with increased use of health care services. Although the other treatable comorbid symptoms, with the exception of pain, are associated with increased service use, their impact varies depending on the type of services provided. Interventions to improve the assessment and treatment of comorbid symptoms, especially pain, among patients with dementia may reduce service needs and thus reduce medical care costs.     

Which veterans go to VA psychiatric hospitals for care: a pilot study

In a study to determine whether certain factors could predict whether veterans seek psychiatric care at a Veterans Administration psychiatric hospital or at other public hospitals, data were collected on 644 visits by veterans to one VA psychiatric hospital and two non-VA public hospitals. Race, alcoholism, number of presenting problems, kind of prior psychiatric hospitalizations, and whether the disability was service-connected were significant factors in distinguishing veterans seeking psychiatric care at the different hospitals. Age, marital status, income, and transiency were not important factors. Minority status and alcoholism appeared to be independent of each other in predicting greater use of the VA hospital.     

Factors associated with high care burden of primary caregivers of children with medical complexity after completing a discharge-support program in a recovery center

IntroductionRecently, many seriously ill children requiring medical equipment are being recommended to transition from hospital to home care in Japan. Since 2011, our recovery center has provided a support program for the transfer process from hospital to home for ill children and their families. The purpose of this study was to evaluate the factors related to high care burden after completing the discharge-support program.MethodsA questionnaire-based cross-sectional study was conducted on all primary caregivers whose children received the program in our center and moved from hospital to home (30 children and 29 families) from May 2011 to May 2018. Fifteen children came from the neonatal intensive care unit. The questionnaire consisted of three parts: characteristics of children and families and life after the program; the Zarit Burden Interview (ZBI); and the Positive and Negative Affect Schedule (PANAS).ResultsTwenty-three primary caregivers responded (79% response rate). All children received tracheostomy and 71% received home mechanical ventilation. Primary caregivers were all mothers. High ZBI score was not related to the severity and type of medical equipment. There were relationships between high ZBI score and following factors: ‘unimproved relationship between patients and family members without primary caregivers’ and ‘additional medical equipment after discharge’. The result of PANAS showed that positive attitude was not different between those with high and low ZBI scores.ConclusionIt is crucial to reach out to family members without a primary caregiver. Additional medical care/equipment after the program is related to the care burden of primary caregivers.     

Does colocated care improve access to cardiometabolic screening for patients with serious mental illness?

Objective

Individuals with serious mental illness (SMI; e.g., schizophrenia, bipolar disorder) experience disparities in mortality relative to the general population, mainly because of medical conditions (i.e., cardiometabolic disease).We assessed whether VA patients with SMI and receiving care from VA mental health facilities with colocated medical care were more likely to receive cardiometabolic risk assessments in accordance with clinical practice guidelines than patients from noncolocated facilities.

Methods

Patients with SMI identified prescribed second-generation antipsychotic medications in fiscal year (FY) 2007 receiving care from VA mental health facilities completing the VA Mental Health Program Survey were included. VA administrative data were ascertained to assess receipt of the following tests every 6 months in FY 2007: body mass index (BMI), blood pressure, lipid profile and fasting glucose.

Results

Out of 40,600 patients with SMI prescribed second-generation antipsychotics, 29% received all cardiometabolic tests (lipid, glucose, BMI and blood pressure). While 79% and 76% received blood pressure and BMI assessments, respectively, only 37% received a lipid test. Patients from colocated sites were more likely to receive all cardiometabolic tests (odds ratio=1.26, 95% confidence interval: 1.18–1.35, P<.001).

Conclusions

Colocated general medical providers in mental health clinics are more likely to provide cardiometabolic assessments for patients with SMI prescribed second-generation antipsychotics.     

A comparison of outcomes among patients with schizophrenia in two mental health systems: a health state approach

This paper introduces a health state modeling approach using clustering and Markov analysis to compare short- and long-term outcomes among health care populations. We provide a comparison to more conventional mixed effects regression methods and show that discrete state modeling offers a richer portrait of patient outcomes than the standard univariate techniques. We demonstrate our approach using primary data from a three year observational study of patients treated for schizophrenia at a VA Medical Center (VA) and in a Community Mental Health Center (CMHC) in the same urban community. Randomly selected samples of outpatients treated for schizophrenia or schizoaffective disorder were interviewed every six months using standardized psychiatric assessments such as the Positive and Negative Syndrome Scale (PANSS). Items from the PANSS were used to define 7 discrete health states representing different levels of severity and diverse mixtures of psychiatric symptoms. Conventional analysis showed that VA patients exhibited increasingly severe symptoms, while CMHC patients remained more stable over the study period. Health state analysis reinforced these results but also identified which subpopulations of VA patients were deteriorating. In particular they showed that there was little change over time among VA patients in the best and worst health states. Instead the deterioration was caused by VA patients with: a) mild symptoms and hallucinations and b) serious positive and negative symptoms, being more likely to enter a state with severe positive and negative symptoms accompanied by moderate general distress.