Over 270,000 Rhode Islanders have a known behavioral health diagnosis, a category that includes various mental health and substance use disorders (SUD). To best serve this population, which represents 35% of insured Rhode Islanders, state agencies in Rhode Island are implementing a range of behavioral health integration and care coordination initiatives that focus on improving care delivery in the state. One opportunity for behavioral healthcare improvement is focusing on hospital admissions that result in potentially preventable readmissions (PPRs).
Hospital stays (known as admissions) are necessary for providing vital care to patients in need of medical treatment. Sometimes patients return to the hospital one or more times following their initial stay, for reasons that include follow-up care or unforeseen complications. These return hospital stays (known as readmissions) are often unavoidable because of the patient's condition, such as when a cancer patient requires multiple rounds of chemotherapy. Other times, however, readmissions are due to causes that potentially could have been avoided. These cases, known as potentially preventable readmissions, are defined as return hospitalizations that are clinically associated with a prior admission, occur within 30 days of the initial admission, and may have been prevented through adequate care during the initial hospital stay, appropriate discharge planning, adequate follow-up after discharge, or better care coordination.
Using 3M's standard, clinically-based methodology, HealthFacts RI has found that substance use disorders and mental health issues are the primary drivers of potentially preventable readmissions in Rhode Island, accounting for over 20% of PPRs in 2013. In other words, individuals admitted to the hospital for a SUD or mental health issue are more likely to have a potentially preventable readmission than individuals admitted for any other reason. This highlights the importance of coordinating care and integrating behavioral health services into primary care and other medical settings.
Admission – An initial hospital stay.
Reason for Admission – The type of healthcare service for which a patient is admitted. Reasons for admission are grouped into 32 broad categories of healthcare services (e.g. orthopedics, mental health, and gynecology).
Readmission – A return hospital stay that may or may not be clinically related to the initial hospital stay.
Potentially Preventable Readmission – A return hospital stay that is clinically related to the initial admission; occurs within 30 days of the initial admission; and may have been able to be prevented through adequate care during the admission, appropriate discharge planning, adequate follow-up after discharge, or better care coordination.
Reason for Readmission – The specific diagnosis for which a patient is readmitted (e.g. post-operative infection or schizophrenia).
PPR Rate – The percentage of admissions that result in one or more potentially preventable readmissions.
Among all reasons for hospital admissions, substance use disorder and mental health admissions most frequently result in potentially preventable readmissions. Specifically, 14% of SUD admissions lead to a PPR. Within the substance use disorder category, the highest PPR rates are found when the initial diagnosis is abuse and dependence on cocaine (17%), opioids (15%), alcohol (14%) or other drugs such as cannabis and sedatives (26%). Thirteen percent of mental health admissions result in a potentially preventable readmission, with PPRs most frequently linked to admissions for adjustment disorders and neuroses (17%), bipolar disorders (15%), schizophrenia (14%) and major depressive disorders (13%).
Mental health conditions and substance use disorders impact potentially preventable readmissions even in cases when they are not the reason for an admission or readmission. In 2013, hospital admissions were 2.5 times more likely to result in a potentially preventable readmission if the patient also had a major behavioral health condition at the time. (For the purposes of this analysis, a major behavioral health condition includes one or more co-occurring mental health and/or substance use disorder diagnoses that were present at the time of the admission. Over two hundred diagnoses fall into this category, with specific diagnoses that include drug-induced mood disorders, alcohol withdrawal, and chronic paranoid schizophrenia.) In particular, admissions that had either a co-occurring mental health or substance use disorder diagnosis were more likely to result in a PPR than those admissions that had neither. Those admissions with both co-occurring mental health and substance use disorder diagnoses had an even higher likelihood of resulting in a PPR.
For example, the PPR rate for urology and nephrology admissions was 7% among patients without a co-occurring behavioral health condition, but 17% among patients with a major behavioral health condition. Admissions related to services such as cardiovascular surgery, pulmonary services, and general surgery also showed wide variance in PPR rates between patients with and without a co-occurring behavioral health condition. These findings demonstrate how behavioral health conditions may exacerbate other health conditions, increase the likelihood of a patient's readmission, and drive up healthcare costs.
In 2013, among substance use disorder admissions that result in a PPR, the most common reasons for the readmission were abuse and dependence on alcohol, opioids, and other drugs such as cannabis and sedatives. These findings demonstrate that substance use disorders often lead to multiple readmissions for the same issues, and require intervention. Return visits for the three most common PPR diagnoses in 2013 cost over $725,000, which represented over half of the total costs for all SUD-related potentially preventable readmissions that year. (The remaining 46% of PPR costs linked to a substance use disorder admission are for other, less frequent, SUD diagnoses as well as various non-SUD diagnoses that were determined to be clinically related to the initial SUD admission, including mental health, general surgery, and infectious disease.) Improving outpatient resources and care coordination for patients with alcohol, opioid and other drug dependencies could potentially help prevent these readmissions and curb their associated costs.
As with SUD-related PPRs, patients who have been admitted to the hospital for mental health issues often return for potentially preventable mental health reasons. Among these, the most common reasons for readmission in 2013 were bipolar disorders, major depressive disorders and other psychoses, and schizophrenia. These readmissions cost over $5 million, representing over 75% of the total cost of all PPRs related to mental health admissions. This highlights a potential opportunity for improved post-discharge follow up and non-emergent care for people with mental health disorders, especially those with bipolar disorders, major depressive disorders, and schizophrenia.
Admissions for mental health and substance use disorders most frequently result in potentially preventable readmissions, and these conditions also increase the risk of a PPR among patients admitted to the hospital for other reasons. While the underlying reasons for these high PPR rates are complex and require further analysis, the data suggest there may be systemic obstacles to accessing high-quality behavioral healthcare, such as insufficient clinical and social support services immediately after discharge, as well as psychosocial challenges that may contribute to poor medication adherence and disease self-management for behavioral health issues. cite cite Other obstacles may include the need for earlier recognition and treatment of mental health and substance use disorders, barriers to obtaining stabilizing medications without prior authorizations, and inappropriate or early discharge from the hospital in response to systemic pressures. (Examples of inappropriate discharges include discharges to homelessness or failure to coordinate discharge with the client's behavioral healthcare provider, possibly due to lack of availability of more appropriate lower levels of care.) These findings highlight the importance of behavioral health integration and care coordination across the healthcare system.
The State is working to address the burden of mental health issues and substance use disorders through several initiatives, including: