Psychiatric readmission of adolescents in the public mental health system

Abstract

The growth of Medicaid managed care in the 1990s has led to substantial changes in the financing and delivery of behavioral health services for children and adolescents. Despite the rapid shift to managed care, few studies have investigated the effect of these changes on service provision to children with serious emotional disturbances. The primary aim of this study was to evaluate the effect of Maryland's Medicaid behavioral health plan on patterns of psychiatric readmission of adolescents. Specific objectives were: (1) to determine whether the rates and frequency of readmissions differed before (Fiscal year 1997) and after (Fiscal year 1998) the implementation of Maryland's Medicaid managed care program; (2) to identify factors that predicted readmission; and (3) to determine the relationship between neighborhood risk factors and readmission. To achieve study objectives, a non-concurrent prospective design was used. The sampling frame consisted of 881 Medicaid-eligible adolescents consecutively admitted to three private psychiatric hospitals between July 1, 1996 and June 30, 1998. Adolescents were followed up for a one year period past their index admission to determine whether they were readmitted to any psychiatric hospital in Maryland. Data was drawn from hospital case records, Medicaid claims data files, and the Area Resource File. While the study findings indicated that there were no significant differences in the overall rates of readmission for the two years, adolescents admitted after the implementation of the managed care program were far more likely to experience multiple readmissions. The cumulative one year rate of readmission was 33% for fiscal year 1997 and 38% for fiscal year 1998. The highest risk period for both years was within the first 30 days post-discharge (14% in 1997 and 13% in 1998). Rates of readmission also varied considerably across hospital providers. Adolescents were more likely to be readmitted if they were younger, had more severe emotional and behavioral disturbances and/or comorbid mental retardation, came from high risk families and had histories of childhood abuse. Type of aftercare services and living arrangements were also important determinants of readmission. Finally, the results indicated that two of the four neighborhood factors (family structure and residential mobility) examined were significantly associated with readmission for the Baltimore sample. Findings revealed that youths who came from areas characterized by high residential mobility, a predominantly African American population, female-headed households, and a high child/adult ratio were less likely to be readmitted. While these findings are counterintuitive, they may suggest racial disparities in access to health care.