Psychiatric Care in General Hospitals With and Without Psychiatric Units (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 14, 2009, Tami L. Mark, Elizabeth Stranges, Rita Vandivort-Warren, Carol Stocks, and Pam Owens made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (3.84 MB).

Slide 1

Psychiatric Care in General Hospitals With and Without Psychiatric Units: How Much and for Whom?�

Tami L. Mark, Thomson Reuters
Elizabeth Stranges, Thomson Reuters
Rita Vandivort-Warren, SAMHSA
Carol Stocks, AHRQ
Pam Owens, Consultant AHRQ

2009 AHRQ Annual Conference
September 14, 2009

Slide 2

Background

Despite the shift from long term inpatient stays to community treatment, hospitalization remains a key component of mental health care today, primarily for people in crisis
Most inpatient psychiatric treatment occurs in general acute care hospitals rather than specialty psychiatric hospitals
General hospital psychiatric care can be provided in two distinct ways
- Psychiatric Units:
  - Set up and staffed specifically for psychiatric treatment
  - Separate, often locked, space within hospital
- "Scatter Beds"
  - General medical care beds located throughout the hospital

Slide 3

Public Policies Affecting Psychiatric Unit Supply and Demand

Decline in beds in public psychiatric hospitals and more recently private psychiatric hospitals

Slide 4

Change in Psychiatric Beds in U.S.

	1970	1976	1980	1986	1990	1992	1995	1998	2000	2002
Non-Federal general hospitals with separate psychiatric services	22,394	28,706	29,384	45,808	53,479	52,059	52,984	54,434	39,690	40,202
Private psychiatric hospitals	14,295	16,091	17,157	30,201	44,871	43,684	42,399	33,408	26,484	25,095
State and county mental hospitals	413,066	222,202	156,482	119,033	98,789	93,058	81,911	68,872	60,675	57,263

Slide 5

Public Policies Affecting Psychiatric Unit Supply and Demand

PPS Exemption of Psychiatric Units, October 1983
Managed Care Limits on Inpatient Care in 1990s
PPS implementation, January 2005
IMD Exclusion encourages use of psych units in community hospitals
- Medicaid will not pay for inpatient treatment for persons age 21-64 who receive care in an "institution for mental disease", defined as an institution of more than 16 beds that primarily treats people with mental illness

Slide 6

Shortage of Psychiatric Beds?

Overcrowding in emergency rooms due to psychiatric patients
Many hospitals report "ED boarding" of patients with psychiatric illness
Survey of state mental health authorities revealed that more than 80 percent of states reported a shortage of psychiatric beds

Slide 7

Research Questions

How much psychiatric care in general hospitals is occurring in psychiatric units and how much in scatter beds?
What types of patients are being treated in psychiatric units and what types in scatter beds?

Slide 8

Motivation

To what extent are patients treated in community hospitals receiving the specialized services that psychiatric units offer?
Are scatter beds being used more in regions where there are not specialized units to supplement psychiatric beds?
Are scatter beds being used primarily to treat medical comorbid conditions or do patients being treated there primarily have psychiatric conditions?

Slide 9

Outline

Data Sources
Prior Research
Part 1: Number of community hospital psychiatric patients treated in psychiatric units vs scatter beds
Part 2: Characteristics of patients treated in psychiatric units and scatter beds
Conclusions

Slide 10

Data Sources on Care in Psychiatric Units

American Hospital Association Survey of Hospitals
Medicare Cost Reports
SAMHSA Survey of Mental Health Specialty Facilities (IMHO, SMHO)
HCUP-SID Revenue Codes

Slide 11

Prior Research

Kiesler & Simpkins: The Unnoticed Majority in Psychiatric Inpatient Care, 1995
Methods
- 1980 Hospital Discharge Survey by NCHS
- Identified psychiatric unit using NIMH survey of psychiatric units (now carried out by SAMHSA) and AHA
Findings
- In 1980, 38% of psychiatric inpatient episodes in community hospitals occurred in scatter beds

Slide 12

Part I: Estimating the Percent of Psychiatric Discharges from General Hospitals in Psychiatric Units and Scatter Beds

Slide 13

Methods

HCUP-SID discharges (2000 - 2006)
- Total number of discharges from community hospitals in participating states
- Examined those with principal psychiatric diagnoses (excluding substance abuse)
Linked to Medicare Cost Report through AHA ID
- Information on whether have PPS exempt psychiatric unit
Checked information on psychiatric unit against volume of MH discharges
- With additional web searching for verification

Slide 14

Study Sample (2006)

U.S. Community Hospitals
4,927
HCUP-SID Hospitals
4,309
(38 States)
AHA-SID-MCR Linked Hospitals
4,220
86% of Community Hospitals

Slide 15

Of Community Hospitals, 27% Have Psychiatric Units, Down from 36% in 2002

Image: Bar graph showing the percent of community hospitals with psychiatric units. The horizontal axis is labeled with the years 2001 through 2006, and the vertical axis shows the numbers 0 through 40 (in units of 5), representing the percent of community hospitals.

There is a bar above each year, showing that:

In 2001 34% of community hospitals had psychiatric units,
In 2002 36% of community hospitals had psychiatric units,
In 2003 31% of community hospitals had psychiatric units,
In 2004 29% of community hospitals had psychiatric units,
In 2005 28% of community hospitals had psychiatric units, and
In 2006 27% of community hospitals had psychiatric units.

Slide 16

About 20% of Discharges are from Hospitals without Psychiatric Units Based on MCR and SID

Image: Bar graph showing the percent of discharges from hospitals with and without psychiatric units based on Medicare Cost Reports and SID. The horizontal axis is labeled with each year from 2001 through 2006, and the vertical axis is labeled 0% through 100% (in units of 10).

There is a bar above each year. Each bar is divided into two parts, represented by two colors, with the bottom portion showing the percent of discharges from hospitals without psychiatric units, and the top portion representing the percent of discharges from hospitals with psychiatric units. The percentages for each year are:

For 2001, 15% of discharges were from community hospitals without psychiatric units, and 85% from those with psychiatric units.
For 2002, 17% of discharges were from community hospitals without psychiatric units, and 83% from those with psychiatric units.
For 2003, 16% of discharges were from community hospitals without psychiatric units, and 84% from those with psychiatric units.
For 2004, 17% of discharges were from community hospitals without psychiatric units, and 83% from those with psychiatric units.
For 2005, 18% of discharges were from community hospitals without psychiatric units, and 82% from those with psychiatric units.
For 2006, 19% of discharges from community hospitals without psychiatric units, and 81% from those with psychiatric units.

Slide 18

Psychiatric Discharges Across States

Slide 19

Summary of Analysis Thus Far

Summary: About 20% of discharges from hospitals without psychiatric units
Maybe over-estimate scatterbeds: Assumes no under-reporting of psychiatric units by hospitals
Maybe under-estimate scatterbeds: Assumes that all discharges from hospitals with psychiatric units are from psychiatric units

Slide 20

Under Reporting Analysis

94% of community hospitals without an MCR psychiatric unit indicator had less than 100 MH discharges (based on HCUP-SID counts).
6% of hospitals without an MCR psychiatric unit indicator had 100 or more MH discharges
39 of the 50 hospitals (78%) with >100 MH discharges but no MCR indicator had a psychiatric unit indicated on their website
Conclusion: Discharge volume can be used to impute missing MCR psychiatric unit status

Slide 21

About 2% of Discharges from Hospitals without Units (If > 100 MH discharges is used as a proxy for a unit)

Slide 22

Over Estimation Analysis

Used revenue codes for room & board charges for 12 states to examine whether discharges had revenue codes indicating psychiatric unit room and board charge
Found 3.6% of discharges from hospitals with psychiatric units were from scatter beds

Slide 23

About 6% of Discharges are from Scatter Beds after Correcting for Under and Over Estimation

Image: Bar graph representing the best estimate of the percent of discharges from psychiatric units and from scatter beds after correcting for under- and over-estimation. The horizontal axis is labeled with each year from 2001 through 2006, and the vertical axis shows the numbers 0% through 100% (in units of 10). There are separate bars above each year from 2001 through 2006. Each bar is divided into two parts, represented by two different colors. The bottom part of each graph shows discharges from psychiatric units, while the top portion of each bar shows discharges from scatter beds.

The values shown for each bar, representing each year are:

For 2001, 2003, 2004, 2005 and 2006, 6% of discharges were from psychiatric units, and 94% were from scatter beds.

In 2002, 5% of discharges were from hospitals without psychiatric units, while 95% were from scatter beds.

Slide 24

Part II: Characteristics of Patients in Psychiatric Units and Scatter Beds

Slide 25

Methods

Used states that had revenue codes that accurately captured room and board
Examined discharges that had a psychiatric room & board revenue code as compared to those from medical surgical rooms

Slide 26

Data

12 HCUP-SID States
Kentucky, Maine, Massachusetts, Nebraska, Nevada, New York, North Carolina, Pennsylvania, Tennessee, Texas, Washington, and West Virginia

Slide 27

Characteristics Examined

Age
Gender
Length of stay
ICD-9-CM mental health diagnoses
Existence of any secondary mental health, substance abuse, or non-mental health substance abuse ICD-9-CM diagnoses
ICD-9-CM Procedures
Total charges
Admission source
Discharge type

Slide 28

Scatter Bed Discharges are More Female

Image: Bar graph showing the percent of females discharged from scatter beds and psychiatric units. The horizontal axis labeled as follows:

Slide 29

Scatter Beds Discharges Are Older

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that were over age 65. The horizontal axis is labeled as follows:

The first label is scatter beds in hospitals without psychiatric units (mean age = 51).
The second label is scatter beds in hospitals with psychiatric units (mean age = 43).
The third label is psychiatric units (mean age =39).
The vertical axis is labeled with the numbers 0 through 100 (in units of 10), representing the percent of discharges that were over age 65.
There are 3 bars.
The first bar shows that 30.3% of discharges from scatter beds in hospitals without psychiatric units were over age 65.
The second bar shows that 20.5% of discharges from scatter beds in hospitals with psychiatric units were over age 65.
The third bar shows that 9.2% of discharges from psychiatric units were over age 65.

Slide 30

Scatter Bed Discharges are More Medicare and Less Medicaid

Image: Bar graph showing the percent of discharges by payer in scatter beds and psychiatric units. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 45 (in units of 5), representing the percent of discharges.
There are 3 sets of 4 different colored bars (colors are repeated in each set).
In the first set of bars showing discharges from scatter beds in hospitals without psychiatric units, about 40% were paid by Medicare, about 17% by Medicaid, about 28% were privately paid, and 10% were uninsured.
In the second set of bars showing discharges from scatter beds in hospitals with psychiatric units, about 28% were paid by Medicare, about 26% by Medicaid, about 32% were privately paid, and 8% were uninsured.
In the third set of bars showing discharges from psychiatric units, about 27% were paid by Medicare, about 33% by Medicaid, about 26% were privately paid, and 8% were uninsured.

Slide 31

Scatter Beds Have Lower Lengths of Stay

Image: Bar graph showing lengths of stay in scatter beds and psychiatric units. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 12 (in units of 2), representing the average number of days.
There are 3 bars.
The first bar shows that the average length of stay was 4 days among discharges from scatter beds in hospitals without psychiatric units.
The second bar shows that the average length of stay was 6 days among discharges from scatter beds in hospitals with psychiatric units. The third bar shows that the average length of stay was 10 days among discharges from psychiatric units.

Slide 32

Scatter Beds have More Emergency Room Admissions

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that were admitted from the emergency room. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 80 (in units of 10), representing the percent of discharges.
There are 3 bars.
The first bar shows that 68.1% of discharges from scatter beds in hospitals without psychiatric units were admitted from the emergency room.
The second bar shows that 60.2% of discharges from scatter beds in hospitals with psychiatric units had been admitted from the emergency room.
The third bar shows that 54.1% of discharges from psychiatric units had been admitted from the emergency room.

Slide 33

Scatter Bed Discharges are More Likely to be Transferred

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that were transferred to another facility. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 25 (in units of 5), representing the percent of discharges.
There are 3 bars.
The first bar shows that 20.6% of discharges from scatter beds in hospitals without psychiatric units were transferred to another facility.
The second bar shows that 17.6% of discharges from scatter beds in hospitals with psychiatric units were transferred to another facility.
The third bar shows that 10.1% of discharges from psychiatric units were transferred to another facility.

Slide 34

Units have more schizophrenia and episodic mood disorders, scatter beds have more anxiety and other nonorganic psychosis

Image: Bar graph showing the percent of discharges by mental health diagnosis from scatter beds or psychiatric units. The horizontal axis labeled as follows:

The first label is schizophrenia.
The second label is episodic mood disorders.
The third label is anxiety disorders.
The fourth label is other non-organic psychoses.
The vertical axis is labeled with the numbers 0 through 60 (in units of10), representing the percent of discharges.
There are 4 sets of 3 different colored bars. The colors are repeated in each set and represent scatter beds in hospitals without psychiatric units, scatter beds in hospitals with psychiatric units, and psychiatric units.
In the first set of bars showing discharges with a diagnosis of schizophrenia, 8% were from scatter beds in hospitals without psychiatric units, 9% were from scatter beds in hospitals with psychiatric units, and 22% were from psychiatric units.
In the second set of bars showing discharges with a diagnosis of episodic mood disorders, 23% were from scatter beds in hospitals without psychiatric units, 29% were from scatter beds in hospitals with psychiatric units, and 54% were from psychiatric units.
In the third set of bars showing discharges with a diagnosis of anxiety disorders, 28% were from scatter beds in hospitals without psychiatric unit, 23% were from scatter beds in hospitals with psychiatric units, and 2% were from psychiatric units.
In the fourth set of bars showing discharges with a diagnosis of other non-organic psychoses, 13% were from scatter beds in hospitals without psychiatric unit, 10% were from scatter beds in hospitals with psychiatric units, and 2% were from psychiatric units.

Slide 35

Scatter beds have more secondary non-MHSA diagnoses

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that had secondary non-mental health or substance abuse diagnoses. The horizontal axis labeled as follows:

The first label is scatter beds in hospitals without psychiatric units.
The second label is scatter beds in hospitals with psychiatric units.
The third label is psychiatric units.
The vertical axis is labeled with the numbers 0 through 100 (in units of 10), representing the percent of discharges.
There are 3 bars.
The first bar shows that 89% of discharges from scatter beds in hospitals without psychiatric units had secondary non-mental health or substance abuse diagnoses.
The second bar shows that 79% of discharges from scatter beds in hospitals with psychiatric units had secondary non-mental health or substance abuse diagnoses.
The third bar shows that 70% of discharges from psychiatric units had secondary non-mental health or substance abuse diagnoses.

Slide 36

Most Discharges Across Settings do not have Procedures Coded

Image: Bar graph showing the percent of discharges from scatter beds and psychiatric units that had procedures performed, as coded on the discharge form. The horizontal axis labeled as follows:

Slide 37

Limitations

Data on psychiatric unit status is imperfect
Data on details of clinical treatment being provided to patients in scatter beds is limited

Slide 38

Conclusions

Psychiatric units may play a more critical role than previously appreciated in ensuring an adequate supply of inpatient psychiatric care
Scatter beds tend to be used for a short amount of time (4 days on average) and 20% of patients are transferred. More likely to be used for older Medicare patients with anxiety although 1/3 have schizophrenia or mood disorders

Slide 39

Policy Implications

There are no U.S. policies to regulate, monitor, or create incentives for adequate access to psychiatric beds across the country
This may need to be addressed to ensure adequate access to inpatient care
Additionally, need to consider how and whether psychiatric units can be supplemented with good quality psychiatric care provided in hospitals without psychiatric units

Slide 40

THANK YOU

Tami.Mark@ThomsonReuters.Com

Current as of December 2009

Internet Citation:

Psychiatric Care in General Hospitals With and Without Psychiatric Units: How Much and for Whom?. Slide Presentation from the AHRQ 2009 Annual Conference (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/about/annualconf09/vandivort_mark_owens.htm

Current as of December 2009

Internet Citation: Psychiatric Care in General Hospitals With and Without Psychiatric Units (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2009/vandivort-mark-owens/index.html