Identifying Innovations for Managing High-Cost Mental Health Patients

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Objectives: Use of psychiatric crisis management (PCM) services - i.e., emergency departments [ED] and acute inpatient psychiatry - contributes substantially to the cost of care for VA mental health patients. Further, prior research outside the VA has shown that a small percentage of patients who utilize these services contribute a disproportionate share of the total cost ("high utilizers"). Despite their high cost, there have been no efforts in the VA to identify the patient characteristics of VA mental health patients who utilize PCM services repeatedly, or (2) formatively evaluate the context of care for these patients in PCM services. The current pilot project will seek to obtain this information in order to identify the treatment needs of, and gaps in the quality of care for, this patient population and develop implementation projects to reduce the cost of VA mental health care. In so doing, this pilot data will lay the groundwork for the PI's emerging program of research focused on the development and implementation of care practices for managing difficult to treat mental health patients. Aim 1: Use VA administrative databases to identify the patient characteristics (demographic; psychosocial; clinical) of high utilizers of PCM services. Aim 2: Use the Consolidated Framework for Implementation Research (CFIR) to conduct a formative evaluation of the context of care for high utilizers of PCM services to better understand (a) patient needs, (b) determinants of existing practices, and (c) barriers and facilitators to practice change with this patient population. Research Design & Methods: A mixed-methods approach will be employed to achieve the proposed aims. To address Aim 1, we will use VA administrative databases to identify all unique mental health patients treated in the VA in FY 2009-2012 (estimated N = 1,740,000); select those who were high utilizers of PCM services (i.e., five or more ED or inpatient psychiatry episodes during any one of the aforementioned fiscal years), and test demographic, psychosocial, and clinical variables as predictors of membership into the high utilizer group. To address Aim 2, we will conduct interviews with directors and mental health providers from PCM services in the VA. We will randomly select 10 VA facilities from the lowest quartile and 10 from the highest quartile in terms of ratio of high utilizers of PCM services to total number of unique mental health patients treated in FY 2012. From each of the 20 facilities selected, we will interview four key informants (directors and front-line mental health providers from EDs and acute inpatient psychiatry; total N = 80) on issues of patient needs and continuity of care (i.e., care coordination; discharge and continuing care planning) using CFIR domains related to the context of care. A comparison of the quantitative and qualitative findings will identify the characteristics and needs of high utilizers of VA PCM services, gaps in the quality of care for these patients, and directions for subsequent implementation projects with these high-cost mental health patients.