Veterans Affairs Health System and mental health treatment retention among patients with serious mental illness: evaluating accessibility and availability barriers.

Access to health services may be understood in terms of distinct dimensions of the fit between characteristics of potential clients and those of providers (Penchansky and Thomas 1981). The influence of specific dimensions of access may be examined with regard to contact with providers, volume of services, and continuity of care (Aday and Andersen 1974; McCarthy and Blow 2004). This study evaluates the impact of two dimensions of access—geographic accessibility and services availability—on longitudinal patterns of health services utilization by patients diagnosed with serious mental illness (SMI). Geographic accessibility refers to the barriers of time and space that must be traversed in order to receive care; availability, to the capacities of providers at a given location to provide care. Studies of geographic accessibility have largely been limited to assessments of effects on contact (receipt of some services), most often inpatient admissions (Joseph and Boeckh 1981; Burgess and DeFiore 1994; Marcus et al. 1997; Fortney et al. 1998; Rosenheck and Stolar 1998; Mooney et al. 2000). Although volume of outpatient care has received more attention over the past decade (Burgess and DeFiore 1994; McCarthy and Blow 2004), few studies have evaluated the impact of accessibility barriers on continuity (Holloway, Vanderbrug, and Bromberg 1990; Piette and Moos 1996; Druss and Rosenheck 1997; Schmitt, Phibbs, and Piette 2003). With few exceptions (Bindman, Keane, and Lurie 1990), availability barriers have been assessed only in terms of volume of institutional care (Ginsburg and Koretz 1983; Brown and Barnett 1992). Among an active patient population, which has evidenced some degree of access to providers, continuity of care is a critical dimension of health system services delivery. Continuity has been described in terms of the availability of patient information, clinician availability and constancy, follow-up after discharge, coordination during transitions, and ongoing provider commitment to the patient (Donaldson 2001). Continuity has also been defined as the extent to which services are received as an “uninterrupted succession of events” consistent with patient needs across illness episodes over time (Shortell 1976). For chronically mentally ill patients, the longitudinal nature of services receipt is critical (Bachrach 1981). Recent studies have operationalized longitudinal measures of continuity of care using administrative data for individuals diagnosed with SMI. Fortney and colleagues found support for the construct validity of duration since last encounter as a continuity measure (Fortney et al. 2003). For outpatient psychiatric and nonpsychiatric services in the Veterans Affairs (VA) health care system, McCarthy examined (1) longest observed gaps in care and (2) percent of annual noninstitutionalized days more than 65 days since previous encounters (McCarthy 2002). These assessments were limited to a 1-year observation period and were specific to either psychiatric or nonpsychiatric services. Few studies have examined long-term gaps over an extended period using measures that encompass both psychiatric and nonpsychiatric care. Patients with SMI, which encompasses schizophrenia and bipolar disorder, frequently require both mental and physical health services (Blow et al. 2003; Bosworth et al. 2004). The VA operates the nation's largest integrated health care system. An ongoing VA policy concern is to assure VA health system treatment retention among patients with SMI (Barry et al. 1999). For these patients, long-term VA health system treatment retention offers a high-level measure of services utilization. VA health system treatment retention offers a global indicator of the patient's continuing engagement with the range of VA services providers. Appropriate care for patients with SMI requires timely contacts, for ongoing assessments, care planning, and evaluation of treatment response (McEvoy, Scheifler, and Frances 1999; Sachs et al. 2000). For patients with schizophrenia who are mildly impaired and in maintenance treatment, expert consensus guidelines recommend at least three outpatient contacts per year (McEvoy, Scheifler, and Frances 1999). Similar minimum contacts are recommended for patients with bipolar disorder (Sachs et al. 2000). Patients over 50 also need at least annual visits for health maintenance tasks (e.g., blood pressure, colon cancer screening, lipid measurement). Unfortunately, patients with SMI are difficult to retain in care (Herinckx et al. 1997). Patient-related barriers to health care include poor insight into their illnesses, difficulty describing their conditions (Goldman 1999), high tolerance for physical pain, and a reluctance to see physicians other than their psychiatrist. Health system barriers to care include stigmatization by providers, complexity of care management (Goldman 1999), and a lack of integration of medical and mental health systems (Druss et al. 2001). Patients, providers, and health care delivery systems face negative consequences from prolonged gaps in care. Patients are at increased risk for negative health outcomes, costly acute care episodes, and mortality. For example, gaps may reduce antipsychotic medication adherence, placing patients with schizophrenia at increased risks of psychiatric hospitalizations (Valenstein et al. 2002). For providers, gaps may disrupt continuity and coordination of care. As a result, providers must perform more comprehensive assessments during patient encounters, and care planning and treatment evaluation become less certain. At the health system level, discontinuities in utilization fragment services delivery, reduce efficiency, and increase the likelihood of costly and preventable acute care episodes. Although health system factors are recognized as barriers to care for patients with SMI (Goldman 1999), few studies have explicitly evaluated their impact on either health system retention or mental health services treatment retention. Existing studies have focused on specific service delivery interventions, such as assertive community treatment and similar intensive case management models, which appear to improve mental health treatment retention (Herinckx et al. 1997). These comprehensive and intensive programs include elements that are relevant to multiple dimensions of access (Penchansky and Thomas 1981), including geographic accessibility (e.g., driving hundreds of miles to visit clients), acceptability (meeting clients on their “own turf”), and accommodation (meeting with clients at their convenience) (Herinckx et al. 1997). However, it is unclear which elements affect retention risks. Moreover, these programs have been restricted to heavy users of inpatient psychiatric care and emergency services, and they have focused narrowly on retention in mental health treatment, although these patients have substantial medical comorbidities (Jeste et al. 1996; Druss and Rosenheck 1997). Owing to the nature and consequences of their psychiatric morbidity, individuals with schizophrenia or bipolar disorder may be particularly sensitive to geographic accessibility and availability barriers (Marcus et al. 1997). In order to improve health services delivery for patients with SMI, it is important to evaluate the influence of health system accessibility and availability on both health system and mental health services treatment retention. In this study, we examine utilization data for patients in the VA health care system with schizophrenia or bipolar disorder. As compared with other health care systems, the VA is thought to present few barriers to care (Jha et al. 2001) with regard to services acceptability and affordability. As a result, this study is able to focus more narrowly on the two focal dimensions of access—geographic accessibility and availability. We test their influence on two measures of continuity of care—health system treatment retention and specifically mental health services treatment retention. These are operationalized in terms of risks of having a 12-month gap in VA health system utilization, and in VA mental health services utilization, from the patient's last VA (or VA mental health) services utilization of FY98 until the end of FY02. Given current treatment practice guidelines specific to patients with SMI and the substantial medical comorbidity among this patient population, we believe that 12-month gaps constitute substantial breaks in both health system and mental health services utilization. For both health system and mental health services retention, we hypothesized that: H1: Patients with SMI who live further from VA providers are more likely to experience a 12-month gap. H2: Patients with SMI with greater availability of VA tertiary care are less likely to experience a 12-month gap. H3: Patients with SMI who have greater availability of non-VA tertiary care will be more likely to experience a 12-month gap.