©2008 Thomson Reuters Psychiatric Care in General Hospitals With and Without Psychiatric Units: How Much and for Whom? Tami L. Mark, Thomson Reuters Elizabeth Stranges, Thomson Reuters Rita Vandivort-Warren, SAMHSA Carol Stocks, AHRQ Pam Owens, Consultant AHRQ 2009 AHRQ Annual Conference September 14, 2009

©2008 Thomson Reuters 2 Background Despite the shift from long term inpatient stays to community treatment, hospitalization remains a key component of mental health care today, primarily for people in crisis Most inpatient psychiatric treatment occurs in general acute care hospitals rather than specialty psychiatric hospitals General hospital psychiatric care can be provided in two distinct ways –Psychiatric Units: Set up and staffed specifically for psychiatric treatment Separate, often locked, space within hospital –“Scatter Beds” General medical care beds located throughout the hospital

©2008 Thomson Reuters 3 Public Policies Affecting Psychiatric Unit Supply and Demand Decline in beds in public psychiatric hospitals and more recently private psychiatric hospitals

©2008 Thomson Reuters Change in Psychiatric Beds in U.S.

©2008 Thomson Reuters 5 Public Policies Affecting Psychiatric Unit Supply and Demand PPS Exemption of Psychiatric Units, October 1983 Managed Care Limits on Inpatient Care in 1990s PPS implementation, January 2005 IMD Exclusion encourages use of psych units in community hospitals –Medicaid will not pay for inpatient treatment for persons age who receive care in an “institution for mental disease”, defined as an institution of more than 16 beds that primarily treats people with mental illness

©2008 Thomson Reuters 6 Shortage of Psychiatric Beds? Overcrowding in emergency rooms due to psychiatric patients Many hospitals report “ED boarding” of patients with psychiatric illness Survey of state mental health authorities revealed that more than 80 percent of states reported a shortage of psychiatric beds

©2008 Thomson Reuters 7 Research Questions How much psychiatric care in general hospitals is occurring in psychiatric units and how much in scatter beds? What types of patients are being treated in psychiatric units and what types in scatter beds?

©2008 Thomson Reuters Motivation To what extent are patients treated in community hospitals receiving the specialized services that psychiatric units offer? Are scatter beds being used more in regions where there are not specialized units to supplement psychiatric beds? Are scatter beds being used primarily to treat medical comorbid conditions or do patients being treated there primarily have psychiatric conditions?

©2008 Thomson Reuters 9 Outline Data Sources Prior Research Part 1: Number of community hospital psychiatric patients treated in psychiatric units vs scatter beds Part 2: Characteristics of patients treated in psychiatric units and scatter beds Conclusions

©2008 Thomson Reuters 10 Data Sources on Care in Psychiatric Units American Hospital Association Survey of Hospitals Medicare Cost Reports SAMHSA Survey of Mental Health Specialty Facilities (IMHO, SMHO) HCUP-SID Revenue Codes

©2008 Thomson Reuters 11 Prior Research Kiesler & Simpkins: The Unnoticed Majority in Psychiatric Inpatient Care, 1995 Methods –1980 Hospital Discharge Survey by NCHS –Identified psychiatric unit using NIMH survey of psychiatric units (now carried out by SAMHSA) and AHA Findings –In 1980, 38% of psychiatric inpatient episodes in community hospitals occurred in scatter beds

©2008 Thomson Reuters Part I: Estimating the Percent of Psychiatric Discharges from General Hospitals in Psychiatric Units and Scatter Beds

©2008 Thomson Reuters 13 Methods HCUP-SID discharges (2000 – 2006) –Total number of discharges from community hospitals in participating states –Examined those with principal psychiatric diagnoses (excluding substance abuse) Linked to Medicare Cost Report through AHA ID –Information on whether have PPS exempt psychiatric unit Checked information on psychiatric unit against volume of MH discharges –With additional web searching for verification

©2008 Thomson Reuters 14 Study Sample (2006) U.S. Community Hospitals 4,927 HCUP-SID Hospitals 4,309 (38 States) AHA-SID-MCR Linked Hospitals 4,220 86% of Community Hospitals

©2008 Thomson Reuters 15 Of Community Hospitals, 27% Have Psychiatric Units, Down from 36% in 2002

©2008 Thomson Reuters 16 About 20% of Discharges are from Hospitals without Psychiatric Units Based on MCR and SID

©2008 Thomson Reuters Psychiatric Discharges Across States

©2008 Thomson Reuters 18 Summary of Analysis Thus Far Summary: About 20% of discharges from hospitals without psychiatric units Maybe over-estimate scatterbeds: Assumes no under-reporting of psychiatric units by hospitals Maybe under-estimate scatterbeds: Assumes that all discharges from hospitals with psychiatric units are from psychiatric units

©2008 Thomson Reuters 19 Under Reporting Analysis 94% of community hospitals without an MCR psychiatric unit indicator had less than 100 MH discharges (based on HCUP-SID counts). 6% of hospitals without an MCR psychiatric unit indicator had 100 or more MH discharges 39 of the 50 hospitals (78%) with >100 MH discharges but no MCR indicator had a psychiatric unit indicated on their website Conclusion: Discharge volume can be used to impute missing MCR psychiatric unit status

©2008 Thomson Reuters 20 About 2% of Discharges from Hospitals without Units (If > 100 MH discharges is used as a proxy for a unit)

©2008 Thomson Reuters 21 Over Estimation Analysis Used revenue codes for room & board charges for 12 states to examine whether discharges had revenue codes indicating psychiatric unit room and board charge Found 3.6% of discharges from hospitals with psychiatric units were from scatter beds

©2008 Thomson Reuters 22 About 6% of Discharges are from Scatter Beds after Correcting for Under and Over Estimation

©2008 Thomson Reuters Part II: Characteristics of Patients in Psychiatric Units and Scatter Beds

©2008 Thomson Reuters 24 Methods Used states that had revenue codes that accurately captured room and board Examined discharges that had a psychiatric room & board revenue code as compared to those from medical surgical rooms

©2008 Thomson Reuters 25 Data 12 HCUP-SID States Kentucky, Maine, Massachusetts, Nebraska, Nevada, New York, North Carolina, Pennsylvania, Tennessee, Texas, Washington, and West Virginia

©2008 Thomson Reuters 26 Characteristics Examined Age Gender Length of stay ICD-9-CM mental health diagnoses Existence of any secondary mental health, substance abuse, or non-mental health substance abuse ICD-9-CM diagnoses ICD-9-CM Procedures Total charges Admission source Discharge type

©2008 Thomson Reuters 27 Scatter Bed Discharges are More Female

©2008 Thomson Reuters 28 Scatter Beds Discharges Are Older

©2008 Thomson Reuters 29 Scatter Bed Discharges are More Medicare and Less Medicaid

©2008 Thomson Reuters 30 Scatter Beds Have Lower Lengths of Stay

©2008 Thomson Reuters 31 Scatter Beds have More Emergency Room Admissions

©2008 Thomson Reuters 32 Scatter Bed Discharges are More Likely to be Transferred

©2008 Thomson Reuters 33 Units have more schizophrenia and episodic mood disorders, scatter beds have more anxiety and other nonorganic psychosis

©2008 Thomson Reuters 34 Scatter beds have more secondary non-MHSA diagnoses

©2008 Thomson Reuters 35 Most Discharges Across Settings do not have Procedures Coded

©2008 Thomson Reuters 36 Limitations Data on psychiatric unit status is imperfect Data on details of clinical treatment being provided to patients in scatter beds is limited

©2008 Thomson Reuters 37 Conclusions Psychiatric units may play a more critical role than previously appreciated in ensuring an adequate supply of inpatient psychiatric care Scatter beds tend to be used for a short amount of time (4 days on average) and 20% of patients are transferred. More likely to be used for older Medicare patients with anxiety although 1/3 have schizophrenia or mood disorders

©2008 Thomson Reuters 38 Policy Implications There are no U.S. policies to regulate, monitor, or create incentives for adequate access to psychiatric beds across the country This may need to be addressed to ensure adequate access to inpatient care Additionally, need to consider how and whether psychiatric units can be supplemented with good quality psychiatric care provided in hospitals without psychiatric units

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