Characteristics and Behavioral healths of Patients with Patterns of High Hospital Use: Implications for Primary Care Providers

Rentas KG, Buckley L, Wiest D, Bruno CA
Source: BMC Health Serv Res
Publication Year: 2019
Patient Need Addressed: Behavioral health, Care Coordination/Management, Homelessness/housing, Substance Use, Trauma
Population Focus: Complex care, Dual eligible, Medicaid beneficiaries
Demographic Group: Racial and ethnic minority groups
Study Design: Other Study Design
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/30732608
Abstract

BACKGROUND:
A small %age of patients relies extensively on hospital-based care and account for a disproportionately high share of healthcare spending in the United States. Evidence shows that behavioral health conditions are common among these individuals, but understanding of their Behavioral healths is limited. This study aimed to understand the behavioral health characteristics and needs of patients with high hospital utilization patterns in Camden, New Jersey.

METHODS:
The sample consisted of patients in a care management intervention for individuals with patterns of high hospital utilization who were referred for behavioral health assessments (N = 195). A clinical psychologist conducted the assessments, which informed a multiaxial evaluation with diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders and a Mental Status Examination, to facilitate accurate diagnosis. Demographic characteristics, housing instability, exposure to trauma, and healthcare service utilization data were also collected through self-report and chart reviews.

RESULTS:
Ninety % of patients were diagnosed with a psychiatric and/or active substance use disorder. Depression was the most common psychiatric disorder and alcohol use was the most common substance use disorder. However, only 10% of patients with an active substance use disorder were in treatment, and only 17% of patients with a mental health diagnosis were receiving mental health treatment. Nearly all (91%) patients reported having a primary care provider at the time of assessment and most had seen their primary care provider within three months of their last hospital discharge. Non-medical barriers to health and wellness, specifically housing instability and exposure to trauma, were also common (35 and 61% of patients, respectively) among patients.

CONCLUSION:
Findings highlight the importance of identifying and treating patients with Behavioral healths in the primary care setting. Developing connections with community agencies who provide behavioral health and substance use treatment can enhance primary care providers’ efforts to address their patients’ non-medical barriers to treatment, as can embedding behavioral health providers within primary care offices. The study also underscores the need for trauma-informed care in primary care settings.

Insights Results

Overview of article

  • This study aimed to understand the behavioral health characteristics and needs of patients with high hospital utilization patterns in Camden, New Jersey

Methods of article

  • The sample consisted of patients in a care management intervention for individuals with patterns of high hospital utilization who were referred for behavioral health assessment
  • A clinical psychologist conducted diagnostic assessments on the patients to facilitate accurate diagnosis. The assessment focused on assessment of psychiatric disorders, substance use disorders, and experiences such as trauma and housing instability to inform and improve care for patients enrolled in the Camden Coalition’s care management intervention
  • Demographic characteristics, housing instability, exposure to trauma, and healthcare service utilization data were also collected through self-report and chart reviews

Results

  • More than one-half (58%) of patients had five or more chronic medical conditions, with hypertension being the most prevalent (75%). In the 6 months prior to intervention enrollment, 91% of patients had between 2 and 4 hospitalizations, 9% had 5 or more hospitalizations, and 37% of patients had 5 or more emergency department (ED) visits. Nearly all patients (91%) indicated they had a primary care provider (PCP), and two-thirds (66%) reported seeing their PCP within 3 months of their last hospitalization
  • Overall, 90% of patients had a psychiatric and/or active substance use disorder at the time of assessment. 83% of patients met criteria for one or more psychiatric disorders, 17% of whom were engaged in treatment for their psychiatric disorder at the time of the assessment. Mood disorders were the most prevalent class (74%). The most prevalent psychiatric disorders were major depressive disorder (45%), bipolar disorder (15%), and posttraumatic stress disorder (15%). 23 patients (12%) reported suicidal ideation at time of assessment

Key takeaways/implications

  • These findings underscore the need for greater knowledge about the obstacles to providing integrated medical and behavioral healthcare in primary care settings, as well as the need for policies and incentives to better support Primary Care Physicians in their efforts to address the Behavioral healths of their patients. Obstacles to providing integrated care may include lack of coordination across medical and behavioral healthcare delivery, limited resources for behavioral health and substance use treatment, patient reluctance to discuss behavioral health issues with their primary care provider, financial and insurance coverage limitations, and challenges in navigating complex healthcare systems
  • This study highlights: 1) The importance of identifying, treating, and referring patients to proper treatment to address patients’ psychiatric and substance use disorders; 2) Need for targeted primary care efforts for mood disorders, alcohol, cocaine, and opioid related disorders; 3) Need to identify and address non-medical barriers (e.g., housing) to treatment; 4) And necessity of trauma-informed integrated physical and behavioral healthcare
  • The study recommends primary care settings implement integrated care strategies, such as routinely assessing all patients for Behavioral healths
  • Limitations to the study include limited generalizability of results. Additionally, no conclusions can be drawn about an association between having a psychiatric and/ or substance use disorder and frequent hospitalizations
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