State Mental Hospital Continuity of Care Study Timothy L. Boaz, Ph.D. Keith Vossberg, B.A. Florida Mental Health Institute May 8, 2001

Background Conducted at PSRDC Dept of Mental Health Law & Policy FMHI/USF Funded by Agency for Health Care Administration Requested by State Human Rights Advocacy Committee

Study Purpose Continuity of treatment for persons discharged from the state hospital has been identified as a problem contributing to recidivism This study used existing administrative data sets to identify factors that may contribute to such problems

Methods Data Sources Florida State Hospital Database (CIS) DCF Community Services Database (IDS) AHCA Medicaid Data System FDLE Criminal History Database Time Frame July 1, 1998 through June 30, 2000.

Indicators of Problems with Continuity of Care Days to restoration of Medicaid benefits Days until onset of services first case management appointment first psychiatric/medication appointment first residential treatment service first therapy appointment Quantity of service received Indicators of problematic events/outcomes Readmission to state hospital Community hospital (ER/CSU) events Criminal justice system involvement (i.e., arrests)

Subjects Discharges (N=1211) from state hospitals – 7/1/ /31/99 Average age43.1 years (16.3% over 55) Gender55.5% male Race71.4% white Hospital episodes> 2 Length of episode708 days (median = 203) Diagnosesschizophrenia 38.8% schizoaffective disorder 25.4% mood disorder 22.9% dementia/cognitive disorder 4.5% other primary diagnoses 8.3%

Medicaid Enrollment Never Enrolled30.0% Previously Enrolled 3.1% Continuously Enrolled18.7% Discharge Enrollees39.7% Subsequently Enrolled 8.4% Limitations -- do not know why subjects were not enrolled have not analyzed Medicaid claims data

Days to Medicaid Enrollment

IDS Service Events Service events reported to IDS/DCF by all providers who have contracts with DCF for clients funded by DCF/ADM contract local match Medicaid TANF 78.5% of subjects had service events reported in the IDS data. Service categories Case ManagementPsychiatric Residential TreatmentTherapy Other MedicalCrisis Crisis Evaluation

Days from Discharge to First IDS Service Event

Services Received after Discharge

Adverse Events Readmitted to state hospital16.4% Received crisis services21.3% Arrested after discharge14.5% Felony arrest after discharge 6.8% Also note 47.3% had a prior arrest 34.4% had a prior felony arrest

Days until Adverse Events

Number Receiving IDS Services by Readmission Status

Number Receiving IDS Services by Adverse Event Experience Status

Outcome Analysis – Case Variables Younger more likely to have adverse events Those with schizoaffective disorder more likely to have adverse events and to be readmitted Those with more episodes more likely to be readmitted Those with prior arrest histories (and felonies only) more likely to have adverse events Not related -- Gender, Race, Length of episode

Outcome Analysis – Service Variables Those who experienced adverse events received more case management service (1 month and 6 months) than those who did not experience such events No other intervention variables were related to readmissions or to experience of adverse events Medicaid enrollment status was related to whether a person received services reported in IDS

Limitations of the Study Data may not show up in analysis reporting deficiencies in data systems errors in matching cases across systems people are not available for follow-up moved out of state died institutionalized elsewhere etc. We have not looked at all the data

Conclusions – Part 1 Significant numbers experienced adverse outcomes following discharge Several case variables are associated with the experience of adverse events. Enrollment in Medicaid (or lack of) was not related to adverse outcomes, but was related to whether the person received services

Conclusions – IDS Services Over 25% had no record of non-crisis, mental health treatment services following discharge (including 30% of those readmitted) Most who received services got case management, but fewer received psychiatric, residential treatment or other therapy Services received were not related to adverse outcomes, except those with crisis events were more likely to have received case management