Medical emergency department utilization patterns among uninsured patients with psychiatric disorders

OBJECTIVE: This study examined medical emergency department utilization for patterns among uninsured patients with psychiatric disorders. METHODS: Billing records of 15,672 uninsured adult patients treated in the emergency department of an academic medical center in southeast Texas over a 12-month period were analyzed for information on demographic characteristics, diagnosis, number of emergency department visits, and hospitalization. RESULTS: Overall, 11.8% of the population was diagnosed as having at least one psychiatric disorder during an emergency department visit. Patients with psychiatric disorders had an increased risk of having multiple emergency department visits and hospitalization compared with patients without psychiatric disorders. The risk of multiple emergency department visits was particularly high for patients with either bipolar disorder or psychotic disorders. CONCLUSIONS: Uninsured patients with psychiatric disorders appear to be heavy users of medical emergency department services. These findings may be helpful in developing more efficient strategies to serve the mental health needs of the uninsured.     

The psychiatric clinical specialist''s impact on psychiatric emergency services

Psychiatric emergency services have evolved into more comprehensive programs during the past two decades. With this evolution other disciplines have gained access to the services and integrated their expertise and philosophy into the daily care of patients. Nursing has been an integral part of this process and contributed its perspective in nursing care. This paper outlines the development of psychiatric emergency services with a special emphasis on the contribution of nursing specialists who have developed their role within the psychiatric emergency service.

What has been unique about the nursing contribution is the attention to individualizing patient care and modifying treatment approaches to meet the patients' needs and interests in psychiatric treatment. Additionally, nursing has complemented the physician's role by developing expertise in assessment that is both psychologically and biologically oriented. Nursing's future contribution to psychiatric emergency services should address mechanisms for tracking patients who enter the psychiatric emergency service system with an emphasis on linkage with other programs or resolution of the crisis episode.     

Characteristics of patients presenting for emergency psychiatric assessment at an English hospital

OBJECTIVE: The needs and characteristics of patients who are referred for psychiatric emergency services vary by the source of referral. Such differences have wider implications for the functioning of the mental health care system as a whole. This study compared three groups of patients in a two-month cohort of 189 patients who were referred for emergency psychiatric assessment at a hospital in England: those who were referred by general practitioners (family physicians), those who were receiving specialist services from community mental health teams, and those who arrived at the hospital from the broader community. METHODS: The three groups were compared on demographic characteristics, clinical and service use variables, risk to self or others, factors that contributed to the emergency presentation, and ratings on standardized scales of functioning. RESULTS: The patients who were receiving specialist services from community mental health teams had high rates of psychosis, often relapsed, and had a history of contact with a psychiatrist. These patients were the most likely to be admitted to the hospital after emergency assessment. The patients who had been referred by general practitioners tended to have fewer indicators of social problems and were more likely to be experiencing a new episode of mental illness. Their referral to the emergency department was most likely to be deemed inappropriate by emergency department clinicians. The patients who came from the broader community were more likely to be male and to exhibit self-harming behavior, substance misuse, and behavioral difficulties. CONCLUSIONS: The rate of emergency referral is one indicator of the functioning of the service system as a whole. Improvements to the system should include better access to community mental health team services and a greater capacity of the primary care system to manage mental health crises. Services need to be developed that are acceptable to male patients who are experiencing social and behavioral problems.     

Use of psychiatric emergency services and enrollment status in a public managed mental health care plan.

OBJECTIVE: This study examined the sociodemographic and clinical characteristics of acute-care psychiatric patients who visited the emergency department at a large public hospital in terms of the patients' enrollment status in the region's public managed mental health care plan. The results of the analyses were expected to provide information about the degree and types of access to care for individuals who are and are not enrolled in the plan. METHODS: Data were collected over a seven-month period for 2,419 patients who visited a large, inner-city crisis triage unit. Patients were grouped according to whether they were currently enrolled, previously enrolled, or never enrolled in the public managed mental health care plan. Univariate and logistic regression models were used to determine differences between the three groups. RESULTS: In general, patients who were currently enrolled in the plan had a higher rate of functional psychosis, past use of psychiatric services, and functional disability and lower rates of substance use and homelessness. Previously enrolled patients had a more moderate rate of psychosis but a higher rate of substance use, functional disability, and homelessness. The never-enrolled patients had a lower rate of psychosis, functional disability, and past use of psychiatric services, and moderate substance use. CONCLUSIONS: The region's public health plan appeared to be succeeding in engaging and keeping the most psychiatrically impaired patients in treatment; however, individuals with moderate psychiatric symptoms and high levels of substance abuse may never have been enrolled in the plan because of Medicaid ineligibility or because they dropped out of treatment. Problematic behavior and history of hospitalization were the best predictors of enrollment status.     

Orienting therapists about patients' needs to increase patient satisfaction

Twenty-nine psychotherapists received orientation about patients' cultural background, expectations, and therapeutic needs. They treated 98 patients before orientation and 73 afterward, and a follow-up interview was conducted 4-6 weeks after completion of therapy. The patients seen after therapist orientation were more satisfied with the services, felt better able to handle problems, were more likely to seek therapy for future problems, and felt more strongly that their needs for clinic services had been met than the patients seen by therapists before orientation. Analyses of therapist experience, patients' ethnicity, and patients' orientation to psychotherapy showed no significant interactions with patient satisfaction.     

Repeated users of a psychiatric emergency service in a Canadian general hospital

The authors of this study examine the demographic and clinical characteristics of repeated users of psychiatric emergency room services in a general hospital. 37.8% of all the patients (913) seen during one year had one or more visits to the emergency room in the six months preceding the index emergency room consultation. Repeaters were more likely than non-repeaters to be unmarried, self referred and with a history of previous psychiatric treatment for a chronic psychiatric disorder. Factors affecting frequency of use of psychiatric emergency room services among different diagnostic groups were also studied. These results demonstrated the heterogeneity of the needs of the diverse diagnostic groups who over-utilize costly emergency room services. Our findings showed that in a country with universal health insurance, psychiatric emergency services also tend to reflect the gaps in the delivery of health services in the hospital and the community.     

Patient-Centered Values and Experiences with Emergency Department and Mental Health Crisis Care

Little is known about what patients value in psychiatric crisis services or how they compare community-based services with those received in the emergency department. Three focus groups (n?=?27) were held of participants who had received psychiatric crisis services in emergency departments or a community mental health center. Participants described care experiences and preferences. Focus groups were audio recorded, transcribed, and coded using a value-based lens. Themes included appreciation for feeling respected, basic comforts, and shared decision-making as foundations of quality care. Participants preferred the community mental health center. Research should address long-term outcomes to motivate change in psychiatric crisis care.     

Repeat visitors in the psychiatric emergency service: a critical review of the data

Repeat visitors to psychiatric emergency services constitute 7 to 18 percent of the total patients and account for up to a third of the visits. This frequently difficult-to-treat group has been described in six controlled and two uncontrolled studies. In a critical review of findings and methodology, the authors interpret and compare the available data about repeaters. Their major conclusions are that repeaters are more likely to lack social supports, to be currently in psychiatric treatment, and to have a chronic illness. Research approaches to further elucidate these patients' characteristics are suggested.     

Preferences for treatment during a first psychotic episode.

Psychiatric services providing care for patients and their families confronted with a first psychotic episode need to be sensitive towards patients' and families' preferences. Ten patients, ten family members and ten professional caregivers composed a list of 42 preferences in the treatment for a first psychotic episode. In total 99 patients, 100 family members and 263 professional caregivers evaluated these preferences, thus producing an order of priorities. There appears to be considerable agreement among the groups of respondents regarding their top ten priorities, especially concerning information on diagnosis and medication. However, we found important differences between groups of respondents. The results suggest that in psychiatric services great attention should be given to psycho-education and early outpatient intervention.     

Psychiatric aftercare: identified needs versus referral patterns

Although psychiatric aftercare has received increased attention, little is known about patients' needs for community resources or about predischarge referral patterns. The authors interviewed hospital staff about needs and referrals for each of 747 patients about to be discharged. Nearly all patients had needs in the medical/therapeutic area and most received referrals. In three other nonmedical aftercare areas needs were identified for a much lower percentage of patients, and identified need was two to three times greater than referrals made. The authors discuss the implications of these findings for the provision of aftercare services.     

What do psychiatric emergency patients really want and how do they feel about what they get?

Psychiatric emergency patients range along a continuum from persons who present to the service with specific requests for help, to individuals who are brought to the service in handcuffs against their will for reasons they do not understand. In addition, studies suggest that psychiatric emergency patients' wishes and expectations often fall outside the traditional framework of psychiatric assessment (1), are not straightforward or concrete (2) or are not accurately perceived by the clinicians who see them (3). How these factors impact on patient satisfaction with the treatment they have received is not well-understood, because the manner in which specific patient variables and treatments might relate to patient satisfaction among the psychiatric emergency service population has not been systematically studied (4) (5) (6). In contrast, psychiatric inpatients and outpatients (7) (8) (9) usually express positive attitudes about their mental health care, although this finding may be skewed by a lack of real anonymity (10). Chronic patients tend to express less satisfaction with their treatment programs than do others, and patient satisfaction in some studies has been related to patient demographics, diagnoses, treatment histories (11) and patients' global rating of treatment outcome (12).     

Psychiatric hospitalization of senile,presenile and arteriosclerotic dementia patients in israel: A psychiatric case register study

Most dementia patients in Israel are cared for by non-psychiatric services. Psychiatric hospitals are generally reluctant to admit behaviourally disturbed dementia patients, unless it is for appropriate psychiatric reasons and for a transient period of time. We used national Psychiatric Case Register (PCR) data to examine the implementation of these criteria in a sample of 711 dementia patients (senile and arteriosclerotic). Results suggest that: (a) in about a third of senile patients and in nearly half of arteriosclerotics no primarily treatable, psychiatric symptoma-tology was diagnosed; (b)most admissions were not on a psychiatric emergency basis; (c)inpatient stay of dementia patients was longer than the average psychiatric admission. These patients were usually transferred to a non psychiatric facility or to a general hospital, or died in the psychiatric hospital. We conclude that the subject of psychiatric hospitalization of dementia patients in Israel needs substantial revision.     

Comparison of urban and rural respondents' experience and opinion of ethical issues in medical care

Ninety-four urban and 54 rural respondents who had undergone hospitalisation in the previous three years were interviewed using a semistructured interview schedule to ascertain their experiences and opinion regarding ethical issues. The interview focussed particularly on patients' satisfaction and expectations about information provided by medical professionals on various aspects of their illness. Results revealed that both the groups were satisfied with the amount of information they had received during their hospitalisation. Rural respondents were comparatively less satisfied with the information they received regarding complications of illness, possible side effects/complications of treatment, and nature of investigations. A higher proportion of urban respondents required information about other available treatment options and possible outcome of illness if left untreated. A higher number of urban respondents felt that provision of information about illness may have harmful consequences to the patient, and more frequently reported that receiving information was the patient's right. These results suggest that although both urban and rural respondents were sensitive to ethical issues, the response of urban respondents from developing countries is more akin to that of their counterparts in the developed countries.     

Psychiatric emergency service use after implementation of managed care in a public mental health system

OBJECTIVE: This study examined whether implementation of managed care in a public mental health system affected return visits to psychiatric emergency services within 180 days of an index visit. METHODS: Data were taken from an administrative database of 75,815 patient visits made to a hospital-based psychiatric emergency service for mental health care between January 1, 1995, and December 31, 2002. Rates of return visits for patients whose index visit occurred at least 26 weeks before a system of managed care was implemented in 1999 were compared with rates for patients whose index visit occurred after the implementation but at least 26 weeks before the data collection period ended. Declining-effects modeling was used to adjust for patients' gender, ethnicity, age, and admission status. RESULTS: A total of 37,371 patients met study criteria for inclusion: 21,135 before managed care was implemented and 16,236 after managed care was implemented. In the pre-managed care group, 3,687 patients (17 percent) made a repeat visit within 26 weeks of their index visit; 2,369 patients (15 percent) in the post-managed care group made such a repeat visit. For any given index visit to the psychiatric emergency department, patients who presented for treatment after managed care were only 90 percent as likely as patients who presented before managed care to have a return visit within the first five weeks after the index visit. However, there was essentially no difference between groups in the likelihood of a return visit by week 26 after the index visit, suggesting that managed care delayed, but did not eliminate, return visits. In addition, the number of police-accompanied index visits continued to rise after managed care was implemented (from 32.0 to 52.6 percent of all index visits), suggesting that increasing numbers of patients with mental illness in need of treatment were coming to the attention of law enforcement officials after managed care was implemented. CONCLUSIONS: Managed care strategies are often used to reduce reliance on emergency services. In this study, managed care delayed, rather than prevented, return visits to the psychiatric emergency service.     

Psychiatric emergency services in a Canadian city: I. Prevalence and patterns of use.

The patterns of use of psychiatric emergency services in Saskatoon, Saskatchewan were studied. A total of 576 patients who had received psychiatric emergency care from any of the four major health care facilities in Saskatoon during a three month period were included in the study. Visits for psychiatric emergency services during the study period represented 2.32% of the total number of visits to emergency facilities. Most patients with psychiatric emergencies went to hospitals with psychiatric units. The characteristics of patients served by the four facilities and those who visited the psychiatric emergency services on more than one occasion during the study period are reported. The implications of these findings for health care planning are discussed.     

The impact of capitated financing on psychiatric emergency services

OBJECTIVE: Studies of capitated financing of mental health services have generally focused on the cost and utilization of services. Relatively little research has addressed whether capitation has an impact on the effectiveness of the mental health system as a whole. This study examined the impact of capitation on hospital emergency department visits, a widely cited indicator of the effectiveness of the other components of the system. METHODS: In 1995 Colorado's Medicaid program instituted capitation for mental health services in two areas of the state, one in which reimbursement of not-for-profit providers was directly capitated and another in which not-for-profit providers partnered with a for-profit managed behavioral health organization. The analysis examined variation over time in the number of emergency department visits by adults who had a primary mental or substance use disorder. Using interrupted time-series methods, visits in areas where reimbursement was capitated were compared with visits in areas where providers continued to be reimbursed on a fee-for-service basis. A total of 105 weeks for each area was examined; capitation was implemented at week 53. RESULTS: The number of psychiatric emergencies treated in capitated areas declined by 814 (28 percent) below the 2,908 psychiatric emergencies expected from trends, cycles, and levels in fee-for-service areas. Findings were similar for for-profit and not-for-profit areas. The decrease persisted through the end of the first year after capitation. CONCLUSIONS: In Colorado the implementation of capitation was associated with a sustained decrease in utilization of psychiatric emergency services provided by hospital emergency departments. Our findings suggest that capitation does not necessarily reduce the quality of care provided to clients.     

A nurse-led self-management intervention for people who attend emergency departments with epilepsy: the patients’ view

Some people with chronic epilepsy (PWE) make clinically unnecessary, and potentially avoidable, visits to hospital emergency departments. Whilst expensive, it is not known how to reduce them. We recently conducted the first trial of an epilepsy-nurse specialist intervention which aimed to optimise self-management skills in PWE attending emergency departments and advise them on appropriate emergency services use. Based on in-depth semi-structured interviews, we here report the perceived support needs of patients who have attended a emergency department for epilepsy and the benefits of the intervention which they identified. Nested qualitative study. After receiving the intervention, 20 participants were invited to interview. They described their experience of the intervention, to what extent they valued it and its benefits and limitations. Interviews were audio-recorded, transcribed and thematically analysed. Most valued the additional support. Those who previously used emergency departments most perceived greatest benefit. Participants felt it redressed limitations to usual care, including providing information about living with epilepsy, and an opportunity to discuss feelings about epilepsy. Perceived benefits included improvements in emotional well-being, confidence dealing with seizures and medication adherence. The intervention was acceptable to patients. People with epilepsy who had attended a emergency department on more than one occasion perceived most benefit. This suggests they want additional care. Some perceived benefits in domains possibly causally related to emergency department use. This suggests the intervention, with optimisation, may have the components to reduce emergency department visits. Our results provide insights into how to support PWE who attend emergency departments and how needs differ amongst this group.     

Patient and contextual factors related to the decision to hospitalize patients from emergency psychiatric services

OBJECTIVE: Mental health care reform has brought an increasing emphasis on community care, with concomitant reductions in inpatient psychiatric resources. Hospitalization remains a necessary and integral component of the mental health care system, but it is taking on a more specialized role. Examining the circumstances in which hospitalization is indicated can help clarify emergency psychiatric practices and determine whether patients' needs are being met within this changing environment. This pilot study examined the impact of selected patient and contextual characteristics on the decision to admit patients to inpatient psychiatric units and assessed the utility of the Severity of Psychiatric Illness (SPI) scale for monitoring clinical practice in emergency psychiatric services. METHODS: Crisis workers in two emergency psychiatric services crisis teams in Toronto, Canada, used the SPI in the assessment of 205 visitors to the services during the winter of 1998-1999. Contextual characteristics, including bed availability, service site, and the admitting physician's level of training, were recorded. Multivariate logistic regression was used to assess the relative contribution of patient and contextual variables in the admission decision. RESULTS: The severity of axis I symptoms and difficulties with self-care were significantly associated with the decision to admit. Site, bed availability, and the admitting physician's level of training did not appear to be associated with clinical decisions. CONCLUSIONS: Patients with the most need are being admitted to inpatient units despite significant systemic pressures on inpatient services. The SPI is a useful and discriminating tool for evaluating clinical practice in emergency services.     

Changes in services and structure in community residential treatment facilities for substance abuse patients

OBJECTIVE: This study examined the extent to which community residential facilities that contract with the Department of Veterans Affairs (VA) to treat substance abuse patients are providing more services and structure to meet the needs of a client population with increasingly severe problems. METHODS: A nationwide sample of 249 community residential facilities with VA contracts was surveyed in 1995 and again in 1998. RESULTS: In 1998 facilities were more likely than they were in 1995 to have psychiatrists and psychologists available to patients as well as specialized counseling and psychoeducational, rehabilitation, and medical services. Facilities also provided more social and recreational activities, and more structure was provided by discouraging patients' choice of individual daily living patterns. In 1998 the facilities were more likely to admit dual diagnosis patients, those with substance use disorders and psychiatric disorders. Programs that changed toward accepting dual diagnosis patients had more services and structure than programs that consistently accepted only substance abuse patients. CONCLUSIONS: Community residential facilities that contract with VA are responding appropriately to an increasingly ill patient population by providing more services and structure.