Psychiatric Care in General Hospitals With and Without Psychiatric Uni

Slide Presentation from the AHRQ 2009 Annual Conferenc

Slide presentation from the AHRQ 2009 conference.

On September 14, 2009, Tami L. Mark, Elizabeth Stranges, Rita Vandivort-Warren, Carol Stocks, and Pam Owens made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (3.84 MB) (Plugin Software Help).

Slide 1

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

 

Slide 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

 

Slide 3

Public Policies Affecting Psychiatric Unit Supply and Demand

  • Decline in beds in public psychiatric hospitals and more recently private psychiatric hospitals

 

Slide 4

Change in Psychiatric Beds in U.S.

 1970197619801986199019921995199820002002
Non-Federal general hospitals with separate psychiatric services22,39428,70629,38445,80853,47952,05952,98454,43439,69040,202
Private psychiatric hospitals14,29516,09117,15730,20144,87143,68442,39933,40826,48425,095
State and county mental hospitals413,066222,202156,482119,03398,78993,05881,91168,87260,67557,263

 

Slide 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 21-64 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

 

Slide 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

 

Slide 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?

 

Slide 8

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?

 

Slide 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

 

Slide 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

 

Slide 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

 

Slide 12

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

 

Slide 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

 

Slide 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
 

 

Slide 15

Of Community Hospitals, 27% Have Psychiatric Units, Down from 36% in 2002

Image: Bar graph showing the percent of community hospitals with psychiatric units. The horizontal axis is labeled with the years 2001 through 2006, and the vertical axis shows the numbers 0 through 40 (in units of 5), representing the percent of community hospitals.

There is a bar above each year, showing that:

In 2001 34% of community hospitals had psychiatric units,
In 2002 36% of community hospitals had psychiatric units,
In 2003 31% of community hospitals had psychiatric units,
In 2004 29% of community hospitals had psychiatric units,
In 2005 28% of community hospitals had psychiatric units, and
In 2006 27% of community hospitals had psychiatric units.

 

Slide 16

About 20% of Discharges are from Hospitals without Psychiatric Units Based on MCR and SID

Image: Bar graph showing the percent of discharges from hospitals with and without psychiatric units based on Medicare Cost Reports and SID. The horizontal axis is labeled with each year from 2001 through 2006, and the vertical axis is labeled 0% through 100% (in units of 10).

There is a bar above each year. Each bar is divided into two parts, represented by two colors, with the bottom portion showing the percent of discharges from hospitals without psychiatric units, and the top portion representing the percent of discharges from hospitals with psychiatric units. The percentages for each year are:

For 2001, 15% of discharges were from community hospitals without psychiatric units, and 85% from those with psychiatric units.
For 2002, 17% of discharges were from community hospitals without psychiatric units, and 83% from those with psychiatric units.
For 2003, 16% of discharges were from community hospitals without psychiatric units, and 84% from those with psychiatric units.
For 2004, 17% of discharges were from community hospitals without psychiatric units, and 83% from those with psychiatric units.
For 2005, 18% of discharges were from community hospitals without psychiatric units, and 82% from those with psychiatric units.
For 2006, 19% of discharges from community hospitals without psychiatric units, and 81% from those with psychiatric units.

 

Slide 18

Psychiatric Discharges Across States

 

Slide 19

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

 

Slide 20

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

 

Slide 21

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

 

Slide 22

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

 

Slide 23

About 6% of Discharges are from Scatter Beds after Correcting for Under and Over Estimation

Image: Bar graph representing the best estimate of the percent of discharges from psychiatric units and from scatter beds after correcting for under- and over-estimation. The horizontal axis is labeled with each year from 2001 through 2006, and the vertical axis shows the numbers 0% through 100% (in units of 10). There are separate bars above each year from 2001 through 2006. Each bar is divided into two parts, represented by two different colors. The bottom part of each graph shows discharges from psychiatric units, while the top portion of each bar shows discharges from scatter beds.

The values shown for each bar, representing each year are:

For 2001, 2003, 2004, 2005 and 2006, 6% of discharges were from psychiatric units, and 94% were from scatter beds.

In 2002, 5% of discharges were from hospitals without psychiatric units, while 95% were from scatter beds.

 

Slide 24

Part II: Characteristics of Patients in Psychiatric Units and Scatter Beds

 

Slide 25

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

 

Slide 26

Data

  • 12 HCUP-SID States
  • Kentucky, Maine, Massachusetts, Nebraska, Nevada, New York, North Carolina, Pennsylvania, Tennessee, Texas, Washington, and West Virginia

 

Slide 27

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

 

Slide 28

Scatter Bed Discharges are More Female

Image: Bar graph showing the percent of females discharged from scatter beds and psychiatric units. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 100 (in units of 10), representing the percent of discharges that were female.
There are 3 bars.
The first bar shows that 62.8% of discharges from scatter beds in hospitals without psychiatric units were female.
The second bar shows that 59.3% of discharges from scatter beds in hospitals with psychiatric units were female.
The third bar shows that 54% of discharges from psychiatric units were female.

 

Slide 29

Scatter Beds Discharges Are Older

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that were over age 65. The horizontal axis is labeled as follows:

The first label is scatter beds in hospitals without psychiatric units (mean age = 51).
The second label is scatter beds in hospitals with psychiatric units (mean age = 43).
The third label is psychiatric units (mean age =39).
The vertical axis is labeled with the numbers 0 through 100 (in units of 10), representing the percent of discharges that were over age 65.
There are 3 bars.
The first bar shows that 30.3% of discharges from scatter beds in hospitals without psychiatric units were over age 65.
The second bar shows that 20.5% of discharges from scatter beds in hospitals with psychiatric units were over age 65.
The third bar shows that 9.2% of discharges from psychiatric units were over age 65.

 

Slide 30

Scatter Bed Discharges are More Medicare and Less Medicaid

Image: Bar graph showing the percent of discharges by payer in scatter beds and psychiatric units. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 45 (in units of 5), representing the percent of discharges.
There are 3 sets of 4 different colored bars (colors are repeated in each set).
In the first set of bars showing discharges from scatter beds in hospitals without psychiatric units, about 40% were paid by Medicare, about 17% by Medicaid, about 28% were privately paid, and 10% were uninsured.
In the second set of bars showing discharges from scatter beds in hospitals with psychiatric units, about 28% were paid by Medicare, about 26% by Medicaid, about 32% were privately paid, and 8% were uninsured.
In the third set of bars showing discharges from psychiatric units, about 27% were paid by Medicare, about 33% by Medicaid, about 26% were privately paid, and 8% were uninsured.

 

Slide 31

Scatter Beds Have Lower Lengths of Stay

Image: Bar graph showing lengths of stay in scatter beds and psychiatric units. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 12 (in units of 2), representing the average number of days.
There are 3 bars.
The first bar shows that the average length of stay was 4 days among discharges from scatter beds in hospitals without psychiatric units.
The second bar shows that the average length of stay was 6 days among discharges from scatter beds in hospitals with psychiatric units. The third bar shows that the average length of stay was 10 days among discharges from psychiatric units.

 

Slide 32

Scatter Beds have More Emergency Room Admissions

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that were admitted from the emergency room. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 80 (in units of 10), representing the percent of discharges.
There are 3 bars.
The first bar shows that 68.1% of discharges from scatter beds in hospitals without psychiatric units were admitted from the emergency room.
The second bar shows that 60.2% of discharges from scatter beds in hospitals with psychiatric units had been admitted from the emergency room.
The third bar shows that 54.1% of discharges from psychiatric units had been admitted from the emergency room.

 

Slide 33

Scatter Bed Discharges are More Likely to be Transferred

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that were transferred to another facility. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 25 (in units of 5), representing the percent of discharges.
There are 3 bars.
The first bar shows that 20.6% of discharges from scatter beds in hospitals without psychiatric units were transferred to another facility.
The second bar shows that 17.6% of discharges from scatter beds in hospitals with psychiatric units were transferred to another facility.
The third bar shows that 10.1% of discharges from psychiatric units were transferred to another facility.

 

Slide 34

Units have more schizophrenia and episodic mood disorders, scatter beds have more anxiety and other nonorganic psychosis

Image: Bar graph showing the percent of discharges by mental health diagnosis from scatter beds or psychiatric units. The horizontal axis labeled as follows:

The first label is schizophrenia.
The second label is episodic mood disorders.
The third label is anxiety disorders.
The fourth label is other non-organic psychoses.
The vertical axis is labeled with the numbers 0 through 60 (in units of10), representing the percent of discharges.
There are 4 sets of 3 different colored bars. The colors are repeated in each set and represent scatter beds in hospitals without psychiatric units, scatter beds in hospitals with psychiatric units, and psychiatric units.
In the first set of bars showing discharges with a diagnosis of schizophrenia, 8% were from scatter beds in hospitals without psychiatric units, 9% were from scatter beds in hospitals with psychiatric units, and 22% were from psychiatric units.
In the second set of bars showing discharges with a diagnosis of episodic mood disorders, 23% were from scatter beds in hospitals without psychiatric units, 29% were from scatter beds in hospitals with psychiatric units, and 54% were from psychiatric units.
In the third set of bars showing discharges with a diagnosis of anxiety disorders, 28% were from scatter beds in hospitals without psychiatric unit, 23% were from scatter beds in hospitals with psychiatric units, and 2% were from psychiatric units.
In the fourth set of bars showing discharges with a diagnosis of other non-organic psychoses, 13% were from scatter beds in hospitals without psychiatric unit, 10% were from scatter beds in hospitals with psychiatric units, and 2% were from psychiatric units.

 

Slide 35

Scatter beds have more secondary non-MHSA diagnoses

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that had secondary non-mental health or substance abuse diagnoses. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 100 (in units of 10), representing the percent of discharges.
There are 3 bars.
The first bar shows that 89% of discharges from scatter beds in hospitals without psychiatric units had secondary non-mental health or substance abuse diagnoses.
The second bar shows that 79% of discharges from scatter beds in hospitals with psychiatric units had secondary non-mental health or substance abuse diagnoses.
The third bar shows that 70% of discharges from psychiatric units had secondary non-mental health or substance abuse diagnoses.

 

Slide 36

Most Discharges Across Settings do not have Procedures Coded

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that had procedures performed, as coded on the discharge form. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 100 (in units of 10), representing the percent of discharges.
There are 3 bars.
The first bar shows that 82% of discharges from scatter beds in hospitals without psychiatric units did not have procedure codes.
The second bar shows that 77% of discharges from scatter beds in hospitals with psychiatric units did not have procedure codes.
The third bar shows that 80% of discharges from psychiatric units did not have procedure codes.

 

Slide 37

Limitations

  • Data on psychiatric unit status is imperfect
  • Data on details of clinical treatment being provided to patients in scatter beds is limited

 

Slide 38

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

 

Slide 39

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

 

Slide 40

THANK YOU

Tami.Mark@ThomsonReuters.Com

Current as of December 2009

Internet Citation:

Psychiatric Care in General Hospitals With and Without Psychiatric Units: How Much and for Whom?. Slide Presentation from the AHRQ 2009 Annual Conference (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf09/vandivort_mark_owens.htm

Current as of December 2009
Internet Citation: Psychiatric Care in General Hospitals With and Without Psychiatric Uni: Slide Presentation from the AHRQ 2009 Annual Conferenc. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/vandivort-mark-owens/index.html