Abstract
Objective
A class-action lawsuit in New York City (Koskinas vs. Cuomo) established the right of psychiatric inpatients to receive discharge planning, including scheduling a first outpatient visit. We examine the rate of attendance of the initial appointment in one city hospital, and whether rates vary among specialty units.
Methods
Retrospective chart review of discharges to outpatient care in 2007–2008 (n=1,884). Multivariate regression models examine the odds of attending the initial appointment.
Results
Patients have a high rate of attending the initial appointment (84%). Case management, living in a shelter or being homeless, medical comorbidity, and being on the dual-diagnosis unit are associated with higher odds of attendance, while non-Latino blacks have lower odds; we found no significant differences for the Latino unit.
Conclusions
Administrators and clinicians may wish to examine the characteristics of their hospital, patient population, and availability of local outpatient services when determining factors influencing continuity of care.
Improving coordination of care is associated with reducing inpatient utilization in favor of outpatient community-based mental health care (1) and improved functional outcomes (2). A first step in establishing continuity of care following discharge from inpatient psychiatric treatment is ensuring that the patient begins outpatient services (3).
Attendance at the first outpatient mental health visit after inpatient discharge varies widely, depending on the clinic setting and population served. A 1989 study of New York City emergency psychiatric admissions found that 70% attended the first outpatient appointment (4); other clinics have found rates of 36%–82% (5–7). Several factors may be associated with propensity to keep the first outpatient appointment. Men (8), Latinos (6), African-Americans (7), and patients with dual substance use and other psychiatric diagnoses (8,9) may be less likely to keep the first appointment. Persons with greater family and social support (6,7), who are older (9), and who have less than a high school education (9) may be more likely to do so.
Given the importance of continuity of care (1), a class-action lawsuit (Koskinas vs. Cuomo) established the right of clients with psychiatric disabilities who are discharged from public psychiatric inpatient units in New York City to receive discharge planning, including housing and outpatient treatment (10). The first outpatient appointment is to be made within seven days of discharge. Hospitals subject to this ruling employ social workers who call providers after the initial appointment date to inquire as to whether it was kept, and follow up with patients who did not attend. This is done regardless of whether the outpatient provider is connected to the hospital system or is located outside the city or state. This study examines rates of attendance at the initial outpatient visit from a hospital subject to the Koskinas ruling, and examines whether attendance varies among specialty inpatient units: a unit geared towards persons with dual substance abuse and psychiatric disorders, a unit geared toward Latino patients, and two randomly chosen general inpatient units.
Methods
A retrospective chart review, compiled from the hospital’s electronic medical record (EMR) and the database maintained by Koskinas social workers, was conducted of all patients discharged from January 1, 2007 to December 31, 2008 in the four psychiatric inpatient units. 2,363 discharges were recorded during this 2-year period. Of those, 2,277 had information on whether the initial post-discharge outpatient appointment was kept. 393 records were excluded because the clients were transferred to other facilities or left against medical advice and thus did not complete the discharge process. 1,884 discharges representing 1,759 unique patients were analyzed. The study was approved by the hospital’s Institutional Review Board.
We examine characteristics associated with attending a first outpatient visit following inpatient discharge in three domains: operational (inpatient unit, receipt of case management), demographic (gender, age, race/ethnicity, preferred language, place of birth, immigration status, insurance status, and housing status), and clinical (presence of substance abuse and medical comorbidities, primary psychiatric diagnosis, and length of inpatient stay). The dependent variable (first-visit attendance) was obtained from the records of follow-up calls to outpatient clinics by social workers. Operational, demographic, and clinical variables were collected at the time of discharge in the hospital’s EMR, and were entered into the model in a stepwise fashion to see whether the association between unit of treatment and receipt of first outpatient visit varied when these variables were added to the model. Multivariate logistic regression was used, with cluster analysis to account for multiple observations among patients. Analyses were conducted using Stata version 13.1.
Results
Table 1 examines characteristics associated with attending the initial outpatient appointment. In the first model, attending the dual-diagnosis unit is associated with higher odds of attending the initial appointment (OR=1.38); no significant association is found for the Latino unit. These associations remain relatively consistent across the four models, as operational, demographic, and clinical variables are included. In the final model, receipt of case management is positively associated with attending the initial appointment (OR=1.53) and non-Latino blacks have lower odds of attending the initial appointment (OR=.57). Persons who live in shelters or are homeless have higher odds of attending the initial appointment, compared to those who are domiciled (OR=2.48 and OR=2.04, respectively). Persons with known medical comorbidities have higher odds of attending the initial appointment (OR=1.36). The online appendix includes sample characteristics, a description of the populations in the specialty units, and a sensitivity analysis using propensity score matching. As in the main analyses, the propensity score matching analysis shows that persons served in the dual diagnosis unit have greater odds of attending the initial appointment, compared to those in general units, and no significant differences are found for those served on the Latino unit.
Table 1.
Probability of attending an initial outpatient appointment (Logistic Multivariate Analysis) (n=1,884)
| Variable | Model 1 Unit only | Model 2 Operational | Model 3 Operational and sociodemographic | Model 4 Operational, sociodemographic, clinical | ||||
|---|---|---|---|---|---|---|---|---|
|
| ||||||||
| OR | 95 % CI | OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Unit (reference: general psychiatric unit) | ||||||||
| Dual-diagnosis | 1.38 | 1.01 to 1.88* | 1.41 | 1.03 to 1.92* | 1.38 | 1.01 to 1.90* | 1.43 | 1.03 to 1.99* |
| Latino | .83 | .62 to 1.12 | .85 | .63 to 1.15. | .68 | 47 to .98* | .69 | .48 to 1.01 |
| Case management present (reference: absent/unknown1) | -- | -- | 1.40 | 1.00 to 1.96 | 1.70 | 1.20 to 2.40** | 1.53 | 1.06 to 2.22* |
| Male (reference: female/unknown2) | -- | -- | -- | -- | .88 | .66 to 1.17 | .92 | .68 to 1.25 |
| Age in years | -- | -- | -- | -- | 1.00 | .99 to1.01 | .99 | .98 to 1.01 |
| Race/ethnicity (reference: White/non-Latino) | ||||||||
| Latino – preferred language Spanish | -- | -- | -- | -- | 1.47 | .81 to 2.671 | .41 | .77 to 2.57 |
| Latino – preferred language English3 | -- | -- | -- | -- | .92 | .61 to 1.38 | .89 | .59 to 1.35 |
| Black, non-Latino | -- | -- | -- | -- | .60 | .43 to.85** | .57 | .40 to .81** |
| Asian, non-Latino | -- | -- | -- | -- | .96 | .26 to 3.48 | .93 | .25 to 3.42 |
| Other, non-Latino | -- | -- | -- | -- | .88 | .41 to 1.91 | .84 | .39 to 1.84 |
| Place of birth (reference: born in US) | ||||||||
| Outside US | -- | -- | -- | -- | 1.31 | .86 to 2.00 | 1.35 | .88 to 2.07 |
| Unknown | -- | -- | -- | -- | 1.07 | .80 to 1.44 | 1.08 | .81 to 1.46 |
| Immigration status (reference: documented) | ||||||||
| Undocumented | -- | -- | -- | -- | .56 | .16 to 1.96 | .60 | .17 to 2.18 |
| Unknown | -- | -- | -- | -- | .82 | .53 to 1.27 | .81 | .52 to 1.25 |
| Insurance (reference: other) | ||||||||
| Public | -- | -- | -- | -- | 1.24 | .82 to 1.87 | 1.17 | .77 to 1.78 |
| Unknown/uninsured4 | -- | -- | -- | -- | 1.40 | .93 to 2.10 | 1.38 | .92 to 2.09 |
| Housing Status (reference: domiciled) | ||||||||
| Shelter | -- | -- | -- | -- | 2.54 | 1.57 to 4.12** | 2.48 | 1.52 to 4.03** |
| Homeless | -- | -- | -- | -- | 2.10 | 1.50 to 2.95** | 2.04 | 1.45 to 2.89** |
| Unknown | -- | -- | -- | -- | 1.00 | .65 to 1.54 | .94 | .60 to 1.47 |
| Medical Comorbidity (reference: absent) | ||||||||
| Present | -- | -- | -- | -- | -- | -- | 1.36 | 1.03 to 1.80* |
| Unknown | -- | -- | -- | -- | -- | -- | 1.86 | .87 to 3.96 |
| Primary Diagnosis (reference: other/none) | ||||||||
| Psychotic disorders | -- | -- | -- | -- | -- | -- | 1.43 | .57 to 3.59 |
| Mood/anxiety disorders | -- | -- | -- | -- | -- | -- | 1.44 | .57 to 3.60 |
| Major depressive disorder with psychotic features/schizoaffective disorder | -- | -- | -- | -- | -- | -- | 1.97 | .74 to 5.25 |
| Adjustment disorders | -- | -- | -- | -- | -- | -- | 1.76. | 53 to 5.86 |
| Substance abuse | -- | -- | -- | -- | -- | -- | 1.27 | .46 to 3.56 |
| Substance abuse present (not primary diagnosis) | -- | -- | -- | -- | -- | -- | .94 | .68 to 1.29 |
| Length of stay (in days) | -- | -- | -- | -- | -- | -- | 1.01 | 1.00 to 1.01 |
p<.05,
p<.01
Three cases with unknown case management were combined with none.
One patient with unknown gender was included in female category.
Three patients had other preferred language, and were included with the English category.
Uninsured could not be distinguished from unknown.
Discussion
Most clients (84%) attended the initial outpatient appointment. This is higher than the rate identified in New York City of 70% prior to the Koskinas ruling (4) and is higher than most published literature in other settings. Consistent with prior literature, we find that non-Latino blacks (7) have lower odds and people who received case management (6) have higher odds of attending the initial appointment. Some of our results, however, are surprising. Persons with medical comorbidities have higher odds of attending the initial appointment, which perhaps reflects greater contact with the health care system. Persons who are homeless or living in a shelter have increased odds of attending the initial appointment, which contrasts findings from other studies (3). In this hospital, many homeless patients are discharged to a shelter closely affiliated with the hospital, and many other local shelters have outpatient mental health treatment available on-site or through mobile units. Therefore, homeless persons discharged from this hospital may be particularly likely to be connected to outpatient treatment, at least immediately after discharge.
Patients treated in the dual-diagnosis unit were more likely to attend the initial appointment than persons treated in other units, even after accounting for the propensity of unit assignment (per appendix). While dual-diagnosis patients generally have lower rates of first-visit attendance (8, 9), less is known about the impact of parallel and integrated treatments on continuity of care (11, 12). The dual-diagnosis unit at this hospital is a training unit in addiction psychiatry. Thus, it is possible that the fellows may have been particularly attuned to interactions with patients and families to ensure continuity of care.
Treatment on the Latino unit was not associated with greater outpatient first-visit attendance. Previous research on ethnically matched inpatient units has provided mixed results. One study found that Latinos and Asians (but not blacks) served on matched units had better referral placement (13, 14). In this local area, there were limited options for outpatient clinics targeted to the Hispanic/Latino community (15). These limited options may have made it difficult, for example, for Spanish-speaking patients to receive a referral close to their home, or at a preferred time or place. Spanish-speaking patients may also have not followed up referrals they knew had limited Spanish-language availability. Regardless, the effects of the limited availability of Hispanic/Latino-focused outpatient providers would have equally affected persons discharged from the Latino and other inpatient units. This may be one reason why patients discharged from the Latino unit did not have visit attendance rates significantly different from the general units.
Study limitations should be noted. This is a retrospective chart review, so we do not have information on how these patients were assigned to units, or how the units communicated discharge instructions. This observational study examines associations only and cannot show causality; comparisons to non-Koskinas hospitals are not made.
Conclusions
Ensuring that patients effectively transition to community-based outpatient services is a key step in ensuring continuity of care following inpatient discharge. Patients at this hospital have a very high rate of attending their first post-discharge appointment, particularly among patients treated in the dual-diagnosis unit, which may reflect the commitment of a training unit with addiction psychiatry fellows to ensuring continuity of care. Other observed findings may also reflect the services available in the hospital and surrounding area. Persons who were homeless or living in shelters had higher rates of attendance, possibly due to the local shelter network. Patients on the Latino unit did not have higher rates of attendance, which may reflect the limited availability of language-concordant outpatient services in the local area.
This study’s findings indicate that, to at least some degree, continuity of care and attendance at the first outpatient visit may depend on the hospital’s resources and the availability of services in the local geographical area. Although previous research has shown poorer continuity of care for persons with dual diagnoses (8, 9), or who are homeless or living in shelters (3), this study’s findings suggest that if the hospital assigns resources to such patients, the continuity of care may be strong. Correspondingly, the limited outpatient services in the community that are targeted to the Hispanic/Latino community may make it difficult to maintain continuity of care, regardless of the quality of services offered to inpatients. Thus, hospital administrators and clinicians who are trying to understand the patient populations that are at risk for poor continuity of care may wish to examine the characteristics of their hospital, patient population, and availability of local outpatient services. Hospitals may look to existing literature to determine populations at risk for poor continuity of care, but then may wish to examine their local situation to determine if their local situation parallels or differs from the study conditions and react accordingly. The results from this study suggest that the reasons for lack of continuity of care, including first outpatient visit attendance, may be strongly influenced by local conditions.
Supplementary Material
Acknowledgments
Dr. H. receives salary support from the National Institute of Mental Health (xxxxxxx). Ms. M receives support from the National Cancer Institute (xxxxxxxxx). Dr. L. receives salary support through an investigator-initiated study funded by Eli Lilly & Co.
The authors thank xxxxxxx xxxxxxx, xxxxxxx xxxxxxxx, and xxxxxx xxxxxxx for consultation and advice and xxxxxx xxxxxx and xxxxxx xxxxx for research assistance.
Footnotes
The authors report no conflicts of interest.
Previous Presentation: None
Contributor Information
Jennifer L. Humensky, Columbia University - Psychiatry, New York. New York State Psychiatric Institute - Division of Behavioral Health Services and Policy Research, New York, New York
Omar Fattal, New York University School of Medicine - Bellevue Hospital.
Rachel Feit, NYU Langone Medical Center, New York, New York.
Sarah D. Mills, San Diego State University/ University of California, San Diego, San Diego, California
Roberto Lewis-Fernandez, Columbia University - Psychiatry, New York, New York. New York State Psychiatric Institute - Center of Excellence for Cultural Competence.
References
- 1.Mitton CR, Adair CE, McDougall GM, et al. Continuity of care and health care costs among persons with severe mental illness. Psychiatric Services. 2005;56:1070–1076. doi: 10.1176/appi.ps.56.9.1070. [DOI] [PubMed] [Google Scholar]
- 2.Greenberg GA, Rosenheck RA. Continuity of care and clinical outcomes in a national health system. Psychiatric Services. 2005;56(4):427–33. doi: 10.1176/appi.ps.56.4.427. [DOI] [PubMed] [Google Scholar]
- 3.Fortney J, Sullivan G, Williams K, et al. Measuring continuity of care for clients of public mental health systems. Health Services Research. 2003;38(4):1157–1176. doi: 10.1111/1475-6773.00168. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Axelrod S, Wetzler S. Factors associated with better compliance with psychiatric aftercare. Hospital and Community Psychiatry. 1989;40(4):397–401. doi: 10.1176/ps.40.4.397. [DOI] [PubMed] [Google Scholar]
- 5.Kruse GR, Rohland BM. Factors associated with attendance at a first appointment after discharge from a psychiatric hospital. Psychiatric Services. 2002;53(4):473–476. doi: 10.1176/appi.ps.53.4.473. [DOI] [PubMed] [Google Scholar]
- 6.Kruse GR, Rohland BM, Wu X. Factors associated with missed first appointments at a psychiatric clinic. Psychiatric Services. 2002;53(9):1173–1176. doi: 10.1176/appi.ps.53.9.1173. [DOI] [PubMed] [Google Scholar]
- 7.Compton MT, Rudisch BE, Craw J, et al. Predictors of missed first appointments at community mental health centers after psychiatric hospitalization. Psychiatric Services. 2006;57:531–537. doi: 10.1176/ps.2006.57.4.531. [DOI] [PubMed] [Google Scholar]
- 8.Cheng KD, Huang CJ, Tsang HY, Lin CH. Factors related to missed first appointments after discharge among patients with schizophrenia in Taiwan. Journal of the Formosan Medical Association. 2014;113:436–441. doi: 10.1016/j.jfma.2012.09.016. [DOI] [PubMed] [Google Scholar]
- 9.Pantalon MV, Murphy MK, Barry DT, et al. Predictors and moderators of aftercare appointment keeping following brief motivational interviewing among patients with psychiatric disorders or dual diagnosis. Journal of Dual Diagnosis. 2014;10:44–51. doi: 10.1080/15504263.2013.867785. [DOI] [PubMed] [Google Scholar]
- 10.Koskinas vs Cuomo. 80 N.Y.2d 684, 610 N.E.2d 348, 594 N.Y.S.2d 675. 1993 Available at http://www.law.cornell.edu/nyctap/I93_0023.htm.
- 11.Mangrum LF, Spence RT, Lopez M. Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders. J Substance Abuse Treatment. 2006;30(1):79–84. doi: 10.1016/j.jsat.2005.10.004. [DOI] [PubMed] [Google Scholar]
- 12.Swindle RW, Phibbs CS, Paradise MJ, et al. Inpatient treatment for substance abuse patients with psychiatric disorders: A national study of determinants of readmission. Journal of Substance Abuse. 1995;7:79–97. doi: 10.1016/0899-3289(95)90307-0. [DOI] [PubMed] [Google Scholar]
- 13.Mathews CA, Glidden D, Murray S, et al. The effect on treatment outcomes of assigning patients to ethnically focused inpatient psychiatric units. Psychiatric Services. 2002;53:830–835. doi: 10.1176/ps.53.7.830. [DOI] [PubMed] [Google Scholar]
- 14.Mathews CA, Glidden D, Hargreaves WA. The effect on diagnostic rates of assigning patients to ethnically focused inpatient psychiatric units. Psychiatric Services. 53:82–829. doi: 10.1176/ps.53.7.823. 200. [DOI] [PubMed] [Google Scholar]
- 15.Lifenet. New York City Mental Health Resource Directory. [Accessed February 3, 2016];Search terms: Hispanic/Latino community and substance abuse outpatient. Available at http://www.800lifenet.org/database.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.