Established outpatient care and follow-up after acute psychiatric service use in youth and young adults

Abstract

Objective:

This study explores follow-up after hospitalization and emergency room use for mental health among youth and young adults with private insurance.

Method:

The IBM^® MarketScan^® Commercial Database (2013-2018) was used to identify people 12-27 years with a mental health hospitalization (n=97,152) or emergency room use (n=108,576). Factors associated with outpatient mental health follow-up within 7 and 30 days of discharge were determined using logistic models with generalized estimating equations accounting for state variation; adjusted Odds Ratio (aOR) and 95% Confidence Intervals (CI) are reported.

Results:

Of those hospitalized, 42.7% received follow-up within 7 days and 64.7% within 30 days. Of those with emergency room use, 28.6% received follow-up within 7 days and 46.4% within 30 days. Type of established outpatient care predicted follow-up, after hospitalization and after emergency room use. As compared to those with no established care, odds of follow-up within 7 days were highest in those with both mental health and primary care (hospitalization aOR=2.81, 95% CI=2.68-2.94; emergency room aOR=4.06, 95% CI=3.72-4.42), followed by mental health care only (hospitalization aOR=2.57, 95% CI=2.45-2.70; emergency room aOR=3.48, 95% CI=3.17-3.82), and primary care only (hospitalization aOR=1.20, 95% CI=1.15-1.26; emergency room aOR=1.22, 95% CI=1.16-1.28). Similar trends were observed within 30 days of acute service use.

Conclusion:

Follow-up care after acute mental health service use among youth and young adults was suboptimal. Having established mental health care strongly predicted follow-up, and more so than having established primary care. Improving engagement with outpatient mental healthcare providers may increase rates of follow-up care.

Introduction

In the past year, the Surgeon General and the Centers for Disease Control and Prevention have warned of an accelerating mental health crisis among adolescents.^1,2 During 2020, 44.2% of high school students experienced persistent sadness or hopelessness, 19.9% seriously considered suicide, and 9.0% attempted suicide.³ Rates of hospitalization and emergency department use for mental illness and substance use disorder are increasing.^4,5 In 2012, mental health and substance use disorders were among the top 10 reasons for hospital stays among teenagers⁶, and from 2009 to 2015 mental health related emergency room visits increased by 56.4% in pediatric patients and 40.8% in adults.⁷

Efforts to improve quality of care for youth and young adults with mental health conditions include increasing rates of follow-up care after acute mental health service use (i.e., hospitalizations, emergency room use). Follow-up with a mental health care provider within 7 and 30 days are national quality measures^8,9 associated with improved medication adherence, decreased suicide risk, and increased healthcare engagement long-term.^10,11 Although about half of Medicaid-insured youth and young adults receive outpatient mental health follow-up,^10,12 estimates among youth and young adults with private insurance are unknown. Youth and young adults may experience unique challenges given they typically interact with multiple systems and agencies^13,14 and may be underserved in current mental health systems.¹⁵

This study sought to determine rates and predictors of mental health follow-up within 7 and 30 days of a hospitalization and emergency room use for a mental health condition among youth and young adults with private insurance and examine differences by age.

Methods

This study was deemed non-human subjects research by the Institutional Review Board of the University of Massachusetts Chan Medical School.

Stakeholder engagement

Stakeholders included representatives from key organizations (see Supplemental Table S1). Two, 1.5-hour virtual forums elicited stakeholder perspectives (one before study launch to ensure that the research generated relevant knowledge, one to share preliminary findings to gain real-world insight in data interpretation).

Dataset

This retrospective cohort study used the IBM^® MarketScan^® Commercial Database (2013-2018), one of the largest collections of nationally representative patient data in the United States.¹⁶ These data include comprehensive, de-identified health insurance claims across the continuum of care (e.g., inpatient, outpatient, carve-out behavioral healthcare) from large employers and health plans who provide private healthcare coverage for employees, spouses, dependents.¹⁶

The inpatient admissions table summarizes information about a hospital admission using certain criteria (e.g., claims related to room and board). This table includes all encounters associated with an admission and includes a variable indicating the principal diagnosis (i.e., the main reason for admission). The outpatient services table includes claims for services in doctors’ offices, hospital outpatient facility, and emergency rooms. Emergency room use claims were defined by place of service, revenue, procedure, or service subcategory code (Table S2).¹⁷ This table includes the first-listed diagnosis associated with the emergency room claim.

Study sample

We created two samples defined by healthcare setting: 1) inpatient hospitalization; and 2) emergency room. Both included patients aged 12-27 years who had an acute event for a mental health diagnosis (i.e., major depressive disorder, bipolar disorder, schizophrenia, other psychotic disorders, anxiety disorders/phobias, post-traumatic stress disorder (PTSD), and disruptive disorders) (Table S3). Individuals with a self-harm or suicide-related code in any of the diagnoses coded were included. We included patients with a primary diagnosis of eating disorders or substance use who had a mental health diagnosis or self-harm/suicide-related claim coded in the remaining diagnosis codes. Those still receiving care at discharge from an inpatient hospitalization (i.e., transferred to another facility, still a patient, other, or missing) were excluded. Patients were excluded if mental health/substance use claims were not covered or were suppressed. If an emergency room visit resulted in an inpatient admission, the patient was included in the inpatient sample rather than the emergency room sample. Those not continuously enrolled during the study period, missing information on health plan coverage, or who had an inpatient/ emergency room visit before an outpatient follow-up visit were excluded. The final samples included 97,152 patients (inpatient) and 108,576 patients (emergency room) (Figures S1 and S2).

Outcome measures

We created two binary outcome variables: outpatient mental health follow-up within 7 and 30 days of discharge from an acute mental health visit. This aligns with national quality measures defined in the Healthcare Effectiveness Data and Information Set (HEDIS).^8,9 HEDIS specifications of follow-up exclude acute visits that are followed by re-admission to inpatient care settings within 30 days of the initial acute care visit; given clinical relevance, we included these visits only if outpatient follow-up care occurred prior to the re-admission. Outpatient mental healthcare was defined as a visit with a specialty mental health provider (e.g., psychiatrist, child psychiatrist) for evaluation, management, psychotherapy, or other psychiatric care including psychiatric facility partial hospitalizations (Table S4).

Secondary outcomes included any follow-up care (primary care and outpatient mental health care). Primary care use included visits with a primary care provider (e.g., internal medicine, family practice, pediatrician) for health promotion, disease prevention, health maintenance and patient education in an outpatient setting.¹⁸ Outpatient care was categorized as primary care or mental health care using provider type, Current Procedural Terminology (CPT) codes, and place of service; outpatient mental healthcare was also defined using specific place of service or service sub-category codes (Table S4). Analysis for those with co-morbid substance use examined substance use specific follow-up care (Table S5).

Exposure measure

The primary determinant was established outpatient care, defined as at least one visit with a provider in the six months prior to the acute mental health event. Use in the six months prior to acute care was explored given previous research examining established care and follow-up rates.¹² Established outpatient care was categorized as primary care and mental health care, mental health care only, primary care only, or none, using the outpatient definitions described above.

Covariates

Covariates included age at time of service (12-17 or 18-27 years), sex (male/female), healthcare plan type, mental health diagnosis, whether the event was self-harm/suicide-related, and medical complexity. Healthcare plan type was categorized as high deductible health plan/consumer driven health plans, basic/ major medical/ comprehensive plan, preferred provider organization, and all others (exclusive provider organization, health maintenance organization, point-of-service). Acute health service use was categorized as self-harm/ suicided-related if the event included any diagnosis code related to suicide (Table S3). The inpatient sample included length of hospital stay (≤3 days, 4 to 6 days, 7 to 10 days, or ≥11 days) and whether the individual left against medical advice. Medical complexity was measured by the Pediatric Medical Complexity Algorithm (less conservative version 3.1).¹⁹ Mental health diagnoses used to define our sample were removed from the algorithm. Individuals were classified as complex chronic (>1 body system involved or ≥1 progressive or malignant condition), non-complex chronic (1 body system involved, not progressive/malignant), and without chronic disease.

Data Analysis

We estimated the proportion of patients who received outpatient mental health care within 7 days and 30 days and described characteristics overall and by the presence of outpatient mental health follow-up. We focused on absolute differences of ≥5% because with large sample sizes trivial differences are likely statistically significant. We quantified the association of established outpatient care with the presence of outpatient mental health follow-up after an acute mental health event, adjusting for available patient-level covariates using generalized estimating equation models to account for clustering by state. Adjusted odds ratios (aOR) and corresponding 95% Confidence Intervals (CI) were estimated. Analyses examined the distribution of established outpatient care by covariates (Table S6–S7), factors associated with any follow-up (Table S8–S9), and stratified by 2-year age intervals (Tables S10–S11), and mental health diagnosis (Tables S12–S13).

Results

Hospitalizations

The average age was 18.9 years (Table 1). The modal number of days in the hospital was 4-6 and 1.5% left against medical advice. The most common primary diagnosis was major depression (53.7%), followed by bipolar disorder (22.3%), and least common was PTSD (0.9%), co-morbid eating disorders (1%), and disruptive disorders (1%). A self-harm, suicidal ideation, or suicide attempt was coded on 56.9% of hospitalizations [most common in major depressive disorder admissions (71.4%, n=36,448); least common in co-morbid eating disorder admissions (11.7%, n=116)].

Table 1.

Individual-level characteristics and acute mental health service use for mental health, 2013-2018

	Inpatient hospitalization (n = 95,153)		Emergency Department Use (n = 108,576)
	N	%	N	%
Age, years
12-17	39,337	41.3	37,393	34.4
18-27	55,816	58.7	71,183	65.6
Female	53,453	56.2	62,857	57.9
Health plan type
Basic/ major medical/ comprehensive	2,890	3.0	2,721	2.5
Preferred provider organization	56,296	59.2	62,138	57.2
High-deductible/consumer-driven	16,221	17.1	20,193	18.6
All other health plans*	19,746	20.8	23,524	21.7
Pediatric medical complexity
Non-chronic	58,788	61.8	76,423	70.4
Non-complex chronic	22,238	23.4	20,947	19.3
Complex chronic	14,127	14.9	11,206	10.3
Left against medical advice	1,447	1.5	N/A
Length of stay, days
3 or less	25,728	27.0
4 to 6	36,879	38.8	N/A
7 to 10	20,741	21.8
11 or more	11,805	12.4
Primary reason for admission
Schizophrenia	4,565	4.8	1,392	1.3
Bipolar disorder	21,225	22.3	7,322	6.7
Major depression	51,061	53.7	24,922	23.0
Anxiety disorders/ Phobias	2,152	2.3	47,826	44.1
Post-traumatic stress disorder	811	0.9	607	0.6
Other psychotic disorders	3,326	3.5	2,964	2.7
Disruptive disorders	950	1.0	4,040	3.7
Substance-use related (co-morbid)**	8,946	9.4	8,309	7.7
Eating disorders (co-morbid)**	992	1.0	153	0.1
Self-harm/ suicide-related event***	54,105	56.9	27,652	25.5
Established outpatient healthcare engagement
Primary care and mental health care	31,811	33.4	28,036	25.8
Mental health care only	27,775	29.2	22,396	25.8
Primary care only	13,906	14.6	24,279	20.6
None	21,661	22.8	33,865	31.2
Mental health care follow-up
Within 7 days	40,619	42.7	31,033	28.6
Within 30 days	64,148	64.7	50,402	46.4

^*All other health plans include: exclusive provider organization, health maintenance organization, point-of-service.

^**Patients were included in this group if the primary diagnosis code for the acute event was for either substance-use or eating disorders (respectively) and they had a code for schizophrenia, bipolar disorder, major depression, anxiety disorders/phobias, post-traumatic stress disorder, other psychotic disorders, or disruptive disorders in any of the remaining diagnosis codes. (See Supplemental Table S2 for details).

^***Patients were classified as having a self-harm or suicide-related event if any diagnosis codes on the acute event were coded (regardless of the mental health conditions above). For this reason, primary reason for admission does not add up to 100%. (See Supplemental Table S2 for details).

About one third had both primary and mental health care use before hospitalization, while 22.8% had no established outpatient care (Table 1). Established care was most common in those with co-morbid eating disorders and least common in those with psychotic disorders (Tables S6–S7). Those of younger age, female, and with complex, chronic conditions had a higher prevalence of established outpatient care.

Mental health follow-up occurred in 42.7% within 7 days and 64.7% within 30 days (Table 1). The strongest predictor of mental health follow-up was established outpatient engagement in the 6 months prior, with type of established care impacting odds of follow-up (Table 2). Compared to those with no established outpatient care, those with both primary care and mental health care had the highest odds of follow-up (within 7-days: aOR=2.81, 95% CI=2.68-2.94). Those with only mental health care had 2.57 the odds (95% CI=2.45-2.70) of receiving mental health follow-up within 7 days of discharge. Those with only primary care had the lowest odds of follow-up as compared to other types of established outpatient care (within 7-days: aOR=1.20, 95% CI=1.15-1.26). Similar patterns were observed in 30-day follow up.

Table 2.

Factors associated with mental health follow-up after hospitalization for mental health, 2013-2018

	7 days			30 days
	follow-up (%)	aOR	95% CI	follow-up (%)	aOR	95% CI
Established outpatient healthcare engagement
Primary care and mental health care	53.0	2.81	2.68-2.94	79.2	3.76	3.51-4.03
Mental health care only	49.4	2.57	2.45-2.70	75.4	3.25	3.06-3.46
Primary care only	31.3	1.20	1.15-1.26	55.5	1.29	1.22-1.35
None	26.3	Ref		47.5	Ref
Age, years
12-17	49.2	1.24	1.20-1.29	75.7	1.42	1.34-1.51
18-27	38.1	Ref		61.6	Ref
Sex
Male	38.6	Ref		62.8	Ref
Female	45.9	1.14	1.11-1.16	71.0	1.16	1.13-1.20
Plan type
Basic/ major medical/ comprehensive	37.0	0.83	0.65-1.06	58.9	0.73	0.53-1.00
Preferred provider organization	43.0	1.07	0.93-1.23	67.8	1.07	0.91-1.27
High-deductible/consumer-driven	43.7	1.08	0.95-1.22	69.1	1.08	0.94-1.24
All other health plans*	41.7	Ref		66.2	Ref
Pediatric medical complexity
Non-chronic	42.0	Ref		67.0	Ref
Non-complex chronic	43.9	1.01	0.98-1.05	68.5	0.98	0.94-1.02
Complex chronic	43.7	1.01	0.97-1.05	67.5	0.94	0.90-0.98
Length of stay, days
3 or less	37.7	Ref		62.1	Ref
4 to 6	44.4	1.21	1.15-1.28	69.8	1.25	1.20-1.30
7 to 10	46.2	1.28	1.21-1.35	71.1	1.30	1.22-1.39
11 or more	41.8	1.13	1.06-1.22	65.0	1.11	1.04-1.19
Left against medical advice
No	42.8	Ref		67.6	Ref
Yes	33.7	0.94	0.83-1.06	52.6	0.78	0.69-0.88
Primary reason for admission
Schizophrenia	38.6	0.83	0.75-0.92	63.1	0.83	0.75-0.91
Bipolar disorder	42.9	0.85	0.81-0.88	68.2	0.81	0.78-0.85
Major depression	46.5	Ref		72.3	Ref
Anxiety disorders/ Phobias	45.8	0.95	0.88-1.02	69.8	0.85	0.78-0.93
Post-traumatic stress disorder	41.8	0.74	0.68-0.81	67.0	0.67	0.58-0.77
Other psychotic disorders	38.9	0.93	0.86-1.01	64.9	1.02	0.94-1.11
Disruptive disorders	34.5	0.58	0.50-0.68	61.2	0.55	0.47-0.64
Substance-use related (co-morbid)**	23.7	0.46	0.41-0.51	41.0	0.37	0.34-0.39
Eating disorders (co-morbid)**	52.4	0.99	0.87-1.13	73.0	0.76	0.62-0.92
Self-harm/ suicide-related***
No	39.7	Ref		63.3	Ref
Yes	44.9	1.03	1.04-1.12	70.6	1.11	1.06-1.16

^*All other health plans include: exclusive provider organization, health maintenance organization, point-of-service

^**Patients were included in this group if the primary diagnosis code for the acute event was for either substance-use or eating disorders (respectively) and they had a code for schizophrenia, bipolar disorder, major depression, anxiety disorders/phobias, post-traumatic stress disorder, other psychotic disorders, or disruptive disorders in any of the remaining diagnosis codes. (See Supplemental Table S2 for details).

^***Patients were classified as having a self-harm or suicide-related event if any diagnosis codes on the acute event were coded (regardless of the mental health conditions above (See Supplemental Table S2 for details).

In most age groups, each type of established outpatient care predicted mental health follow-up within 7 days (Table S10). Established outpatient including mental health (with or without primary care) predicted mental health follow-up regardless of primary diagnosis code (Table S12).

Older age and leaving against medical advice were associated with decreased odds of mental health follow-up (Table 2). Female sex, hospitalizations related to self-harm/suicide, and longer length of stay was associated with increased odds of mental health follow-up. Compared to those hospitalized for major depression, those hospitalized for schizophrenia, bipolar disorder, PTSD, disruptive disorders, and co-morbid substance use disorder had decreased odds of mental health follow-up within 7 days or 30 days. The primary reasons for hospitalization associated with mental health follow-up within 7 days differed slightly by age group (Table S10). Of those hospitalized for substance-use disorder, 23.7% (n=2,124) received follow-up within 7 days, and 41.0% (n=3,668) within 30 days. Of those with co-morbid substance use disorder as the primary reason for hospitalization, 43.2% (n=3,780) had substance-use specific follow-up (not included in the outpatient mental healthcare definition explored) within 7-days and 54.6% (n=4,780) within 30 days.

Emergency room visits

Of those who used the emergency room for mental health the average age was 19.5 years. The majority were female (57.9%), had a preferred provider organization plan type (57.2%), and had no chronic health conditions other than mental illness (70.4%) (Table 1). The primary diagnosis code was anxiety/phobias (44.1%) and major depression (23.0%). One in four visits carried a code for self-harm, suicidal ideation, or suicide attempt [most common in major depressive disorder (34.7%, n=8,645); least common in anxiety disorders (3.7%, n=1,750)]. Nearly one third lacked established outpatient care before emergency room use. Mental health follow-up was observed in 28.6% within 7 days and 46.4% within 30 days. Any follow-up increased this to 34.1% within 7 days and 55.5% within 30 days (Table S8).

The strongest predictor of mental health follow-up was established outpatient engagement (Table 3). Compared to those with no established outpatient care, those with both primary care and mental health care had the highest odds of follow-up (within 7-days: aOR=4.06, 95% CI=3.72-4.42). Those with mental health care had 3.48 the odds (95% CI=3.17-3.82) of follow-up within 7 days, after adjusting for all other covariates. Those with primary care had the lowest odds of follow-up as compared to other types of established outpatient care (within 7-days: aOR=1.22, 95% CI=1.16-1.28).

Table 3.

Factors associated with mental health follow-up after emergency room use for mental health, 2013-2018

	7 days			30 days
	follow-up (%)	aOR	95% CI	follow-up (%)	aOR	95% CI
Established outpatient healthcare engagement
Primary care and mental health care	44.9	4.06	3.72-4.42	69.2	5.47	5.10-5.87
Mental health care only	39.9	3.48	3.17-3.82	63.8	4.53	4.16-4.93
Primary care only	18.5	1.22	1.16-1.28	32.4	1.26	1.21-1.31
None	14.8	Ref		26.2	Ref
Age, years
12-17	36.9	1.42	1.34-1.50	57.0	1.43	1.36-1.51
18-27	24.2	Ref		40.9	Ref
Sex
Male	27.0	Ref		44.5	Ref
Female	29.7	1.00	0.97-1.03	47.8	1.00	0.97-1.03
Plan type
Basic/ major medical/ comprehensive	26.6	0.96	0.81-1.15	43.6	0.90	0.74-1.09
Preferred provider organization	29.0	1.07	0.95-1.21	46.8	1.06	0.93-1.20
High-deductible/consumer-driven	28.8	1.05	0.95-1.15	46.8	1.06	0.95-1.16
All other health plans*	27.5	Ref		45.3	Ref
Pediatric medical complexity
Non-chronic	27.8	Ref		45.2	Ref
Non-complex chronic	30.2	1.01	0.98-1.04	48.7	1.02	0.98-1.05
Complex chronic	30.7	0.98	0.94-1.02	50.3	1.00	0.96-1.05
Primary reason for admission
Schizophrenia	26.4	0.90	0.75-1.08	47.1	1.02	0.85-1.22
Bipolar disorder	33.0	1.03	0.93-1.14	55.6	1.22	1.12-1.34
Major depression	37.8	1.35	1.28-1.42	59.0	1.52	1.46-1.59
Anxiety disorders/ Phobias	24.2	Ref		39.4	Ref
Post-traumatic stress disorder	39.7	1.42	1.13-1.78	56.5	1.30	1.12-1.51
Other psychotic disorders	22.6	0.89	0.79-1.00	41.1	1.05	0.93-1.17
Disruptive disorders	30.5	0.83	0.77-0.90	50.8	0.91	0.82-1.01
Substance-use related (co-morbid)**	18.9	0.62	0.59-0.66	33.8	0.62	0.59-0.66
Eating disorders (co-morbid)**	45.1	1.37	1.05-1.78	66.0	1.38	0.97-1.95
Self-harm/ suicide-related***
No	26.6	Ref		43.6	Ref
Yes	34.3	1.20	1.12-1.27	54.6	1.29	1.23-1.36

^*All other health plans include: exclusive provider organization, health maintenance organization, point-of-service

^**Patients were included in this group if the primary diagnosis code for the acute event was for either substance-use or eating disorders (respectively) and they had a code for schizophrenia, bipolar disorder, major depression, anxiety disorders/phobias, post-traumatic stress disorder, other psychotic disorders, or disruptive disorders in any of the remaining diagnosis codes. (See Supplemental Table S2 for details).

^***Patients were classified as having a self-harm or suicide-related event if any diagnosis codes on the acute event were coded (regardless of the mental health conditions above). (See Supplemental Table S2 for details).

In most age groups, each type of established outpatient care predicted mental health follow-up within 7 days (Table S11). Established outpatient including mental health (with or without primary care) predicted mental health follow-up regardless of primary diagnosis code (Table S13). Older age was associated with decreased odds of mental health follow-up, while use related to self-harm/suicide was associated with increased odds (Table 3).

Compared to emergency room use for anxiety disorders/ phobias, increased odds of follow-up were observed in major depression, PTSD, and bipolar disorder (30 days only); those utilizing the emergency room for disruptive disorders (7 days only) and co-morbid substance use had decreased odds. The primary reasons for hospitalization associated with mental health follow-up within 7 days differed slightly by age group (Table S11). Of those with emergency room visits for substance-use, 18.9% (n=1,574) had mental health follow-up within 7 days (33.8%, n=2,804 within 30 days). For those with co-morbid substance use as the primary reason for emergency room use, 11.5% (n=957) had substance-use specific follow-up with 7-days, and 17.9% (n=1,485) within 30 days.

Discussion

Over 50% of youth and young adults privately insured lacked mental health follow-up within 7 days of a hospitalization or emergency room use for mental health. Established outpatient care was the strongest predictor of follow-up. Those exhibiting self-harm/suicide had higher odds of follow-up, yet over 50% did not receive follow-up within 7 days of acute service use. Rates of follow-up (mental health and substance-use specific) were notably low in those with co-morbid substance use disorder.

Our findings are consistent with previous research indicating that having established care increases odds of follow-up after acute service use.¹² To our knowledge, we are the first to show that type of established care impacts rates of follow-up. Youth and young adults with both primary care and mental health care had the highest odds of follow-up. These results highlight that establishing patients with both primary care and mental healthcare is essential to improving follow-up after acute mental healthcare use. Given the well-documented shortage of mental health professionals,²⁰ primary care has become the de-facto mental health care system.²¹ Our study suggests that primary care, when functioning alone in the current health system, might be less able to connect youth and young adults with mental health conditions to recommended specialty care in a timely manner. Improving rates of follow-up after acute service use for mental health is one of many reasons to support national efforts to integrate primary and mental health care.^22–25 Additionally, increased access to Coordinated Specialty Care would likely be beneficial for many of these youth, especially those experiencing first episode psychosis.²⁶ This is a team-based, recovery-oriented intervention demonstrated to decrease hospitalization rates and increase education and employment rates.²⁷

Alarming suicide trends in youth are well documented^28,29 and exacerbated by the COVID-19 pandemic.^30,31 Suicide risk is significantly increased after emergency room use or hospitalization.³² In several studies, follow-up care after acute service use for suicide attempt has been associated with lower risk of suicide re-attempt and suicide death, making this particularly important in those exhibiting symptoms of self-harm, suicidal ideation, or suicide attempt.^10,33 The majority of hospitalizations were suicide-related, yet 55.1% of those exhibiting suicide-related symptoms did not receive follow-up after discharge. Emergency room use related to suicide was relatively low, likely because emergency room visits resulting in a hospitalization were included in the inpatient sample. This may have produced an emergency room sample that disproportionately included those with anxiety/phobias, which had the lowest prevalence of suicide-related symptoms. Given these considerations, the 65.7% who did not receive follow-up within 7 days of emergency room use related to suicide represent a major gap in care. Efforts such as the Zero Suicide Initiative aim to prevent suicide for those under the care of health systems.³⁴ An effort to improve transitions in care through increased follow-up after acute service use could target suicide prevention in high-risk youth, potentially by requiring follow-up appointments at hospital discharge for those with suicide risk factors. Additionally, the potentially iatrogenic effects of inpatient psychiatric care emphasize the need to prevent hospitalization entirely,³⁵ potentially via national efforts such as The 988 Hotline to provide specialized care during mental health crisis.³⁶

About one third of those who used the emergency room for mental health condition lacked established outpatient care and less than 50% received mental health follow-up within 30 days of discharge. Low rates of outpatient healthcare utilization are well-documented in the young adult population.^37–39 Given patients in our study were privately insured and had a documented mental health diagnosis, these low rates are concerning. Emergency room care is typically less comprehensive and shorter than inpatient hospitalizations, providing less opportunity to set up follow-up care. This could be improved by increasing utilization of case management⁴⁰ and requiring a follow-up appointment at discharge. Of all mental health conditions explored, those with co-morbid substance use as the primary reason for emergency room use had the lowest rates of follow-up care (overall and substance-use specific). Recent efforts have focused on follow-up care for adults with co-morbid substance use disorder, given the high rates of hospital re-admission and post-discharge mortality in this population.⁴¹ With the rising rates of substance-use related deaths⁴² and youth-related concerns,⁴³ these trends require more detailed research.

Study limitations include identification of mental health being limited to diagnostic codes as no information regarding functional status was available. The validity of administrative claims data and diagnostic codes in identifying mental health diagnoses is documented.^16,44 We lacked racial/ethnic information and other social determinants. Mental health care may be received in settings not included in this data, such as schools or out-of-network spending. Nevertheless, this study is the first to examine the associations between established outpatient care and follow-up rates after acute mental health care in privately insured youth.

Conclusions

In conclusion, these findings underscore the importance of increasing rates of established outpatient mental health and primary care to improve follow-up rates after acute service use for mental health among youth and young adults. Integration of primary and mental health care may help achieve optimal follow-up rates. In emergency room settings, special attention should be given to those with co-morbid substance use and those exhibiting signs of self-harm or suicide.

Highlights:

• Of youth and young adults who visited the emergency room for mental health, 28.6% received follow-up within 7-days and 46.4% within 30-days.

• Follow-up within 7 days of discharge from a hospitalization for mental health was observed in 42.7% of youth and young adults (64.7% within 30 days).

• The strongest predictor of follow-up was having established both primary care and mental healthcare in the 6 months prior to acute service use.

• Follow-up rates were notably low in those with co-morbid substance use disorder.