National Meeting 2007

1042 — Distance Limits Initiation of Mental Health Intensive Case Management Services among High-Risk Patients with Serious Mental Illness

McCarthy JF (HSR&D / SMITREC; University of Michigan) , Valenstein M (HSR&D / SMITREC; University of Michigan), Visnic S (SMITREC), Slade EP (VA VISN 5 MIRECC; University of Maryland)

Objectives:
As the locus of VA psychiatric services has shifted from inpatient to outpatient settings, patients with serious mental illness (SMI) have become increasingly reliant on Mental Health Intensive Case Management (MHICM) services. MHICM services are designed to support functional independence and community reintegration among patients with SMI who are at high risk for rehospitalization. Ensuring adequate and equitable access to MHICM care is a priority for the VA. We assess whether non-clinical factors, in particular geographic accessibility barriers, may limit eligible patients’ initiation of MHICM services.

Methods:
Using the VA’s National Psychosis Registry, we identified all 7047 patients who in FY03 qualified for MHICM services (>30 psychiatric days of stay or >=3 psychiatric stays); received diagnoses of schizophrenia, bipolar disorder, or other psychoses; and had received no MHICM services during FY03 or in the prior two years. MHICM initiation was indicated by use of MHICM services in FY04. In sensitivity analyses, we also examined sustained use (>=0.8 visits/week, prorated for time following initial use). Generalized Estimating Equations with a logistic link were used to adjust variance estimates for the clustering of patients within facilities. We assessed distance from the patient’s residence at the start of FY04 to the nearest MHICM team. Other covariates included age, gender, race/ethnicity, marital status, service connection, substance abuse, psychiatric inpatient days in FY03, presence of an on-site MHICM team in the last inpatient psychiatric stay of FY03, and number of available MHICM slots at the nearest location.

Results:
478 patients (6.8%) received MHICM services, and 217 (3.1%) had sustained use in FY04. Patients were significantly more likely to receive MHICM if they were younger (OR=1.10 per 5 years), female (OR=1.65), or unmarried (OR=1.37). Those living farther from MHICM sites were less likely to receive services (OR=0.95 per 10 miles). Similar results were observed for sustained use. Patients who were homeless were less likely to have sustained use (OR=0.51).

Implications:
Many eligible patients fail to receive MHICM services. Distance barriers limit MHICM use.

Impacts:
Focused efforts are needed to improve initiation and delivery of MHICM services for eligible patients, particularly for those in remote locations.