Study: Established outpatient care preceding acute psychiatric services improves incidents of follow up

By Christina P. O'Neill
January 6th, 2023
Brian Skehan, MD, Ph.D, assistant professor, UMass Chan Medical School
Brian Skehan, MD, Ph.D, is an assistant professor at UMass Chan Medical School.

Follow up outpatient care after hospitalization and emergency room use for mental health issues was determined to be ‘suboptimal,’ among youth and young adults with private insurance, according to a study published in ps.psychiatryonline.org.

The study sought to define rates and predictors of mental health care follow up within seven and 30 days after an inpatient hospitalization or ER visit by privately insured youth and young adults ages 12-27.

Average hospitalization inpatient age was 18.9 years; of those who visited the ER for a mental health reason, the average age was 19.5 years.

The authors found that 42.7 percent of post-hospitalization patients with private insurance received follow up within seven days, and 67.4 percent within 30 days. Among post-ER visit patients, 28.6 percent received follow up within seven days, while 46.4 percent received follow up within 30 days.

Co-author Brian Skehan MD, Ph.D., assistant professor at UMass Chan Medical School, said the report “highlights that the healthcare community has not been able to ensure adequate follow up for patients after a psychiatric emergency.”

“Ensuring follow up care through having a scheduled appointment before leaving the ED or psychiatric hospital would be one way to hopefully improve these quality measures.” --Brian Skehan, MD, Ph.D, assistant professor, UMass Chan Medical School

He said researchers were aware from previous work that approximately 50 percent of youth insured by Medicaid receive outpatient mental health follow up but that the data was unknown regarding follow up outcomes for youth with private insurance.

In the cited study, the hypothesis that follow up could be better with private insurance with better access to providers and potentially higher reimbursement did not turn out to be true, he said.

“Ensuring follow up care through having a scheduled appointment before leaving the ED or psychiatric hospital would be one way to hopefully improve these quality measures,” Skehan said.

Another factor is the different approaches to care systems between the pediatric and adult care systems. Skehan said while pediatric providers may make multiple outreach calls to families or individuals as a result of the patient’s dependent status, “In many cases, adult [care] providers will assume that an individual is no longer seeking care after a missed appointment or [an unanswered outreach call].”

Response “can be difficult for youth who have mental illness who often exhibit psychological delays in development and may not have had the experience or modeling to navigate the adult health care system.”

The study utilized the IBM MarketScan commercial database ranging from 2013 to 2018 (pre-COVID). Challenges included youth and young adult interactions with multiple mental health systems. Study subjects had experienced an acute event stemming from a mental health condition, including suicide- and self-harm, eating disorders or substance use disorder with a psychiatric diagnosis or self-harm or suicide-related codes.

Those with previously established outpatient care, as well as its type, increased the likelihood of follow up care as compared to having only established primary care.

About a third of subjects had primary and mental health care during six months prior to hospitalization, while 22.8 percent had no established outpatient care. Patients who were younger, female, and with complex chronic conditions had a higher incidence of established outpatient care.

Those hospitalized for schizophrenia, bipolar disorder, PTSD, disruptive disorders or comorbid substance use disorder were less likely to receive follow up within either seven days or 30 days.

Excluded from the study were subjects still receiving care at inpatient discharge or those who were still patients. Also excluded were individuals who had missing data, uncovered or suppressed claims, as well as those without continuous private insurance coverage during the study period.

The study’s findings indicate that previously established outpatient care was the strongest predictor of follow up care after acute service, the authors noted.

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