How many people in managed care plans receive timely follow-up care after being hospitalized for a mental illness?

Among managed care plan members who were hospitalized for a mental illness, more than one-half in private plans but only two of five in Medicare and Medicaid plans received follow-up care within seven days. By 30 days after hospital discharge, three-quarters of private plans but only about three of five in Medicare and Medicaid plans had received follow-up care.

Why is this important?

• There were 2.3 million hospitalizations for mental disorders in the United States during 2003 (CDC 2005). About two of five patients hospitalized for a psychiatric condition are rehospitalized within one year, often because of poor adherence to prescribed medications (Klinkenberg and Calsyn 1996).
• Follow-up care after a hospitalization for mental illness supports the patient's transition back to the community and may reduce rehospitalizations for some individuals (Klinkenberg and Calsyn 1996, 1998) or help facilitate necessary readmission before individuals reach a crisis stage (NCQA 2005a).
• The National Committee for Quality Assurance (NCQA), an accreditation and quality watchdog group, developed several measures of mental health care quality that are used by health care purchasers and regulators to monitor the performance of managed care plans on these topics.

Findings

Among managed care enrollees who were hospitalized for a mental illness in 2005, almost one-half of those in private plans and three of five of those in Medicaid and Medicare plans did not receive follow-up within seven days of hospital discharge. Moreover, one-quarter of those in private plans and about two of five in Medicare and Medicaid plans still had not received follow-up after 30 days.

Performance improved modestly (by 5 to 8 percentage points) in private plans from 2000 to 2005, but rates changed very little (no more than 4 percentage points) in Medicaid and Medicare plans (NCQA 2005a).

Implications

• Other studies have reported similar gaps in mental health aftercare (Klinkenberg and Calsyn 1996). Even when follow-up appointments are scheduled for patients, many fail to keep them (Boyer et al. 2000). These results suggest a need for more robust methods of assuring follow-up care.
• Worse performance for follow-up of Medicare and Medicaid beneficiaries may reflect general deficits in mental health care for the elderly and access barriers for those with low income. Systemic improvements are needed in the nation's mental health care system to address such factors (PNFCMH 2003).

Improvement Ideas and Resources

In addition to making follow-up appointments and reminding patients to keep them, some studies suggest that "bridging" interventions increase the likelihood that patients will engage in mental health aftercare (Boyer et al. 2000; Kopelowicz et al. 1998; Reynolds et al. 2004), such as by:

• communicating discharge plans to the patient's ambulatory care provider;
• starting outpatient programs before hospital discharge;
• teaching patients to practice skills for reentering the community; and
• providing peer support and transitional care by inpatient staff.

More rigorous evaluations are needed to test and identify effective interventions that can be recommended for widespread adoption.

Measure:

• The denominator includes health plan members ages six and older who were hospitalized for treatment of selected mental health disorders (depression, schizophrenia, attention deficit disorder, and personality disorders), and who were enrolled continuously during the seven- or 30-day follow-up period. The denominator excludes patients who were directly transferred or readmitted within 30 days to a nonacute facility for mental health treatment or to a nonacute or acute facility for non-mental health treatment, and it may exclude individuals who lack, or who have exhausted, outpatient mental health coverage.
• The numerator contains those in the denominator population who had an "an ambulatory mental health encounter or intermediate treatment with a mental health practitioner" within seven or 30 days following hospital discharge (NCQA 2006b).

Limitations:

Additional research is needed to determine the relationship between mental health aftercare and rehospitalization and the type, frequency, and other characteristics of aftercare that are most beneficial to patients.

Source:

National Committee for Quality Assurance (NCQA 2006) Quality Compass data represent Health Plan Employer Data and Information Set (HEDIS) results submitted to NCQA for public dissemination by commercial and Medicaid health plans. NCQA collects Medicare HEDIS data on behalf of the Centers for Medicare and Medicaid Services (CMS) from all Medicare managed care plans that CMS requires to report HEDIS data. Data for this measure are collected from administrative claims data.

References:

* Indicates source of data used in the chart(s).Boyer, C. A., D. D. McAlpine, K. J. Pottick et al. 2000. Identifying Risk Factors and Key Strategies in Linkage to Outpatient Psychiatric Care. American Journal of Psychiatry 157 (10): 1592–8. CDC (Centers for Disease Control and Prevention). 2005. 2003 National Hospital Discharge Survey. Advance Data from Vital and Health Statistics 359. Klinkenberg, W. D., and R. J. Calsyn. 1996. Predictors of Receipt of Aftercare and Recidivism Among Persons with Severe Mental Illness: A Review. Psychiatric Services 47 (5): 487–96. Klinkenberg, W. D., and R. J. Calsyn. 1998. Predictors of Psychiatric Hospitalization: A Multivariate Analysis. Administration and Policy in Mental Health. 25 (4): 403–10. Kopelowicz, A., C. J. Wallace, and R. Zarate. 1998. Teaching Psychiatric Inpatients to Re-enter the Community: A Brief Method of Improving the Continuity of Care. Psychiatric Services 49 (10): 1313–6. * NCQA (National Committee for Quality Assurance). 2006a. The State of Health Care Quality, 2006. Washington, D.C.: National Committee for Quality Assurance. NCQA (National Committee for Quality Assurance). 2006b. HEDIS 2006 Technical Specifications. Washington, D.C.: National Committee for Quality Assurance. PNFCMH (President's New Freedom Commission on Mental Health). 2003. Achieving the Promise: Transforming Mental Health Care in America. Final Report.Reynolds, W., W. Lauder, S. Sharkey et al. 2004. The Effects of a Transitional Discharge Model for Psychiatric Patients. Journal of Psychiatric and Mental Health Nursing. 11 (1): 82–8.