Continuity of Care After Inpatient Discharge of Patients With Schizophrenia in the Medicaid Program: A Retrospective Longitudinal Cohort Analysis

Objective: This study seeks to identify patient, facility, county, and state policy factors associated with timely schizophrenia-related outpatient treatment following hospital discharge.

Method: A retrospective longitudinal cohort analysis was performed of 2003 national Medicaid claims data supplemented with the American Hospital Association facility survey, the Area Resource File, and a Substance Abuse and Mental Health Services Administration Medicaid policy report. The analysis focuses on treatment episodes of adults, aged 20 to 63 years, who received inpatient care for ICD-9-CM-diagnosed schizophrenia (59,567 total treatment episodes). Rate and adjusted odds ratio (AOR) of schizophrenia-related outpatient visits within 7 days and 30 days following hospital discharge are assessed.

Results: Of the 59,567 hospital discharges, 41.7% received schizophrenia-related outpatient visits in 7 days and 59.3% in 30 days following hospital discharge. The adjusted odds of 30-day follow-up outpatient visits were significantly related to preadmission outpatient mental health visits (AOR‘ ‰=‘ ‰3.72; 99% CI, 3.44-4.03), depot (AOR‘ ‰=‘ ‰2.83; 99% CI, 2.53-3.18) or oral (AOR‘ ‰=‘ ‰1.73; 99% CI, 1.62-1.84) antipsychotics as compared with no antipsychotics, and absence of a substance use disorder diagnosis (AOR‘ ‰=‘ ‰1.35; 99% CI, 1.25-1.45). General hospital as compared with a psychiatric hospital treatment (AOR‘ ‰=‘ ‰1.32; 99% CI, 1.14-1.54) and patient residence in a county with a larger number of psychiatrists per capita (AOR‘ ‰=‘ ‰1.27; 99% CI, 1.08-1.50) were related to receiving follow-up outpatient visits. By contrast, residence in a county with a high poverty rate (AOR‘ ‰=‘ ‰0.60; 99% CI, 0.54-0.67) and treatment in a state with prior authorization requirements for‘ ‰<‘ ‰12 annual outpatient visits (AOR‘ ‰=‘ ‰0.69; 99% CI, 0.63-0.75) reduced the odds of follow-up care.

Conclusions: Patient characteristics, clinical management, geographical resource availability, and the mental health policy environment all appear to shape access to care following hospital discharge in the community treatment of adult schizophrenia.

J Clin Psychiatry 2010;71(7):831-838

Submitted: January 8, 2010; accepted March 8, 2010.

Online ahead of print: April 20, 2010 (doi:10.4088/JCP.10m05969yel).

Corresponding author: Mark Olfson, MD, MPH, Department of Psychiatry, Columbia University/ New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY 10032 ([email protected]).