# Presentation: 516355

## Private Hospitals and the Treatment of Severe Mental Illness: The Role of the Emergency Department Presented by:  	Richard C. Lindrooth, Ph.D.		Medical University of South Carolina	Charleston, SCCo-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)

## 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

## 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?

## 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....

## 		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

## 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

## 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

## 	      Access to Care

- 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
*	*

- 	      Access to Care

## Methods

## 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.

## 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

## Schizophrenia only

|   | Base | 1997-1998 & 2002-2005 | State Interactions |
| --- | --- | --- | --- |
| Specialty Psych Beds in HRR (100) | -0.0148* | -0.000485 | -0.0263*** |
|  | (0.00781) | (0.0106) | (0.00797) |
| Psych Unit Beds in HRR (100) | 0.00927*** | 0.0143*** | 0.00145 |
|  | (0.00233) | (0.00314) | (0.00237) |
| State Psych Beds Per Capita | -0.236*** | -0.298*** | -0.0821*** |
|  | (0.0237) | (0.0350) | (0.0158) |
| Psych Emergency in HRR (10) | -0.213*** | -0.492*** | -0.151*** |
|  | (0.0267) | (0.0409) | (0.0273) |
| Psych Partial Hosp. in HRR (10) | -0.353*** | -0.351*** | -0.221*** |
|  | (0.0468) | (0.0636) | (0.0501) |
| EDs in HRR (10) | 0.233*** | 0.367*** | 0.188*** |
|  | (0.0199) | (0.0286) | (0.0210) |
| Free-standing MH Outpatient in HSA ($1000) | 0.0326 | 0.0956** | 0.0323 |
|  | (0.0289) | (0.0417) | (0.0302) |
| Free-standing MH Residential in HSA ($1000) | -0.159*** | -0.203*** | -0.138*** |
|  | (0.0505) | (0.0727) | (0.0533) |
| Hospital-based Psych Outpatient in HSA (10s) | 0.170*** | 0.170** | 0.147*** |
|  | (0.0494) | (0.0711) | (0.0484) |

## Schizophrenia versus Dementia/Mood

| Public Schizophrenia Admissions Relative to: |  |  |  |
| --- | --- | --- | --- |
|   | Schizphrenia | Dementia  | Mood Disorders |
|  | Private | Public | Private |
| Specialty Psych Beds  | -0.0121 | -0.0333*** | 0.0251** |
|  | (0.00812) | (0.00937) | (0.0102) |
| Psych Unit Beds | -0.000995 | -0.00261 | -0.0101*** |
|  | (0.00229) | (0.00243) | (0.00264) |
| State Psych Beds  | -0.0966*** | -0.0679*** | 0.00436 |
|  | (0.0233) | (0.0250) | (0.0260) |
| Psych Emergency | -0.260*** | -0.177*** | -0.259*** |
|  | (0.0272) | (0.0301) | (0.0336) |
| Psych Partial Hosp. | -0.141*** | -0.192*** | 0.0271 |
|  | (0.0459) | (0.0504) | (0.0547) |
| EDs | 0.227*** | 0.195*** | 0.154*** |
|  | (0.0209) | (0.0228) | (0.0251) |
| Free-standing MH Outpatient  | 0.0193 | -0.105*** | -0.124*** |
|  | (0.0293) | (0.0318) | (0.0378) |
| Free-standing MH Residential  | -0.136*** | 0.00322 | 0.102 |
|  | (0.0520) | (0.0574) | (0.0698) |
| Hospital-based Psych Outpatient  | 0.191*** | 0.321*** | 0.323*** |
|  | (0.0483) | (0.0528) | (0.0642) |

## Results

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

## 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

## Research ongoing....

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