Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3042 — Reinstitutionalization Following Psychiatric Discharges of Patients with Serious Mental Illness: A National Longitudinal Study

Irmiter CA (U-M Dept of Psychiatry; SMITREC) , McCarthy JF (VA HSR&D; SMITREC), Soliman S (VA HSR&D), Barry KL (VA HSR&D; SMITREC), Blow FC (VA HSR&D; SMITREC; U-M Dept of Psychiatry)

Objectives:
VA patients diagnosed with serious mental illnesses (SMI) are a highly service-connected vulnerable patient subpopulation with high risks of acute care episodes. Among all patients with SMI who had inpatient psychiatric discharges in FY98, we examined the prevalence, timing, and risk factors for reinstitutionalization (to hospital, nursing home, or other 24-hour institutional care settings) from the initial discharge in FY98 through FY05.

Methods:
From the VA’s National Psychosis Registry, we identified 34,670 patients diagnosed with schizophrenia or bipolar disorder with an inpatient psychiatric discharge in FY98. Using multivariable survival analyses, we examined patient (age, gender, marital status, homelessness, service connection, substance abuse/dependence, SMI diagnosis, and medical comorbidity) and index stay characteristics (length of stay) as they relate to re-institutionalization. Analyses used covariance sandwich estimators to adjust for the lack of independence among individuals discharged from the same facility. Observation time was right censored at the end of FY05, with death modeled as a competing risk.

Results:
Through FY05, 30,417 patients (87.7%) were reinstitutionalized. 4,253 patients (12.3%) were not; 789 (2.4%) died prior to reinstitutionalization, and 3,464 (9.9%) were right-censored. Of patients who were reinstitutionalized, 73% were admitted to inpatient psychiatry, 20% to inpatient non-psychiatric beds, 1.2% to nursing homes, and 5.8% to residential rehabilitation or domiciliary/vocational care settings. Reinstitutionalization to inpatient psychiatry beds occurred sooner (mean days 333 [SD=506] vs. 536 [SD=666]; p<0.001) than for patients re-institutionalized to other settings. Patients had increased risks of reinstitutionalization if they had higher Charlson comorbidity index scores (HR=1.08), were service connected (HR=1.09), had substance abuse (HR=1.21), or were homeless (HR = 1.45). Patients who were married had lower risks (HR=0.91).

Implications:
Over the seven years following psychiatric discharges, nearly 9 of 10 SMI patients were reinstitutionalized. Those who were homeless, with more comorbidities, and fewer supports had greatest risks.

Impacts:
Study findings may inform policy, funding, and clinical care decisions to further reduce the cost of care while enhancing a continuum of care. For the most vulnerable subpopulation, VA’s focus should be to enhance patient’s functional independence and integration into community settings through early intervention and best practice care (ACT, permanent housing, and integrative medical care).