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  1. Private Hospitals and the Treatment of Severe Mental Illness: The Role of the Emergency DepartmentPresented by: Richard C. Lindrooth, Ph.D. Medical University of South Carolina Charleston, SCCo-authors: Anouk L. Grubaugh, Ph.D., MUSC Walter Jones, Ph. D, MUSC Anthony Lo Sasso, Ph. D., University of Illinois, Chicago B. Christopher Frueh, Ph. D., University of Hawaii, Hilo Research support: 2 RO1 HS010730-04 (AHRQ PI: Lindrooth) R01 MH074151-01 A2 (NIMH PI: Lindrooth) K24-MH074468 (NIMH PI: Frueh)

  2. Background • What is the role of acute psychiatric beds in the continuum of community care? • Are the a safety valve for the system of community care? • What could stem the observed growth in admissions through the ED? • Main outcome of this paper is admissions through the ED

  3. Inpatient Psychiatric Care • State Inpatient Beds • Treatment of the severely mentally ill (SMI) • Deinstitutionalizaion began in the 1960s • Shifted patients to community care • Better treatments enabled patients to function in the community • Role of Acute Care Beds • Acute episodes • A safety valve?

  4. Community Psychiatric Care • Partial Hospitalization Programs • Stabilize patients avoid admissions • Psychiatric specialty emergency care • ED staffed by psychiatric specialists • Residential and Foster Care • Long-term care • Outpatient • Psychiatrists (MD); psychologists; case-managers; therapists; etc….

  5. Policy Question • To what extent can ED admissions to acute care hospitals be prevented with access to community alternatives? • Outpatient MHSA Clinics • MHSA Residential Care • Community housing Services/Shelters • Partial hospitalization • Psychiatric emergency facilities • Supply of long-term beds

  6. Prevalence of SMI in Community • Cannot observe directly… • Use the closure of state beds to proxy for an increase in SMI. • In the context of a large reduction in beds: • What aspects of community care prevent psychiatric admissions through the ED? • Hospital outpatient • Psychiatric Emergency /partial hospitalization • MHSA residential options • Acute Beds

  7. Identification Strategy • Treatment group: Patients with public insurance in states that experience major downsizing in state beds 1997-2000. • Schizophrenia and other psychoses represented the largest portion of the SMI. • Control Group: Zip codes within a state that experienced little change in the supply of state beds between 1997-2000 • Public dementia patients and private mood disorder patients • Pre-period: 1997-2000 • Post-period: 2001-2005

  8. Access to Care • Measured spatially based on the patient’s zip code: • Indicate whether a hospital-based ED, Psychiatric Unit, or Stabilization/Partial Hospitalization Unit is in the HRR (HRR) • Number of long term/state psychiatric beds (beds) • Indicate whether hospital outpatient, freestanding outpatient or freestanding MHSA Residential is within the patient’s HSA (HSA) Data from AHA Annual Survey (cleaned and smoothed) and Census of Economic Activity

  9. Methods

  10. HCUP-SID Data • AZ, CO, FL, NJ, NY, WA, & WI discharge data 97-05 • Patients admitted to ED with primary ICD9 Code Treatment (Common diagnoses for persons w/ SMI) : • CCS Code 659 for Schizophrenia other psychotic disorders (Public payer= Medicare; Medicaid; Other public; Self) Comparison (Less common diagnoses for person w/ SMI): • CCS Code 653 for Delirium, dementia, and amnestic and other cognitive disorders (Public Payer) • CCS 657 Mood disorders (Private Payer) • Sample includes all admissions from ED to acute care hospitals.

  11. Methods • Fixed Effect Negative Binomial Regression • Zip code fixed effects (Include runs with State*Year FE) • Sample Year 1997-2005 • Pre-period 1997-2000 (T=0) • Post-period 2001-2005 (T=Change in beds b/w 97-00) • Unit of analysis: Counts by zip code per year • Dependent Variable: Number of ED Admissions in zip

  12. Schizophrenia only

  13. Schizophrenia versus Dementia/Mood

  14. Results • Partial hospitalization programs reduce admissions through the ED • Especially when combined with a psychiatric emergency department. • Results consistent and robust

  15. Results and Conclusions • Results consistent across several different specifications (i.e. discrete changes; closest ED type etc….) • Partial hospitalization programs with Psychiatric emergency consistently reduce admissions through the ED • Access to residential treatment facilities also consistently reduces admissions through ED. • Access to state beds plays a large role (unsurprising) • Acute bed capacity matters; but not as consistent

  16. Research ongoing…. • Next steps: • Add more states and years (CA data next) • Endogeneity of Acute Closures • Examine LOS, discharge destination, and court-ordered admissions

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