Study Examines Effects and Costs of Mobile, Team-Based Outpatient Care Model for Veterans with Serious Mental Illness
Assertive Community Treatment (ACT) — called Mental Health Intensive Case Management (MHICM) in VA — is a mobile, team-based outpatient service model for providing comprehensive psychiatric care and case management support to individuals with serious mental illness (SMI) who intensively use inpatient psychiatric care. For these individuals, traditional outpatient services may not be adequate to prevent the need for acute care. Using data from all VA ACT programs from FY01 through FY04, this observational study assessed the impacts of entry into an ACT program on newly enrolled Veterans' psychiatric inpatient utilization and mental health costs during the first 12 months of program enrollment. Investigators examined both the average program impact and differential program impacts for Veterans with greater vs. fewer mental health inpatient bed days before program entry. These measures were compared for ACT enrollees (n=2,010) and Veterans who met eligibility criteria for ACT services (n=4,020) but did not enroll in the program.
- The proportion of ACT enrollees admitted to inpatient mental health care did not differ significantly from non-enrollees admitted (62% vs. 63%). However, compared to non-enrollees, ACT enrollees had 16 fewer mental health inpatient bed days during the first 12 months of enrollment.
- For ACT program participants, savings depended on new clients' "intensity" of psychiatiric inpatient utilization prior to entering the ACT program. VA ACT services are cost-saving for Veterans with serious mental illness and more than 95 mental health inpatient bed days in the 12 months prior to entering ACT, but cost-increasing for Veterans with fewer than 95 bed days.
- Between FY01 and FY04, new VA ACT clients had just over 68 bed days in the 12 months prior to entering ACT on average, and their entry into ACT was estimated to result in an increase of $4,529 in VA mental health costs.
- Trends in psychiatric inpatient use among ACT program entrants remained stable after FY04, through FY10. However, eligibility for ACT declined by 37% because fewer Veterans met eligibility based on high prior inpatient use. Thus, authors suggest that the "high hospital use" criterion may impose a trade-off between program cost-effectiveness and program access. Fewer Veterans are attaining the high hospital use threshold as inpatient use falls. This winnowing of the target population may indicate a need to reconsider the administrative criteria for entry into VA ACT services.
- The results were based on administrative data only and, consequently, do not provide information on clinical outcomes associated with entry into VA ACT services.
- This study only examines data from FY01 to FY04. Because the characteristics of patients participating in the program may have evolved over subsequent years, the current relevance of the results may require confirmation.
This study was funded by HSR&D (IIR 06-115). Drs. McCarthy and Valenstein and Ms. Visnic are part of HSR&D's Center for Clinical Management Research and VA's National Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, MI.
Slade EP, McCarthy JM, Valenstein M, Visnic S, and Dixon LB. Cost Savings from Assertive Community Treatment Services in an Era of Declining Psychiatric Inpatient Use. Health Services Research May 17, 2012;e-pub ahead of print.