Rates of Inpatient and Emergency Room Use Before and After Discharge Among Medicaid Enrollees in OnTrackNY

Predictors of relapse and engagement in care one year after ending services in an urban safety net coordinated specialty care program for first episode psychosis

OBJECTIVE

This study aimed to identify risk factors for relapse (psychiatric emergency department visits or hospitalization) and lack of follow-up with outpatient psychiatric care in the 12 months after ending services in an urban safety net coordinated specialty care (CSC) program for first episode psychosis (FEP).

METHODS

The study population (n = 143) were individuals with FEP who had any CSC care between 2014 and 2021. To identify risk factors for relapse and follow up after exit, multivariable logistic regression was performed using data from electronic health records and linked insurance claims data.

RESULTS

Individuals with any emergency department visit or hospitalization 12 months prior to ending CSC (aOR = 4.69, 95 % CI 1.78-12.34) and those who were using cannabis at last CSC contact (aOR = 4.06, 95 % CI 1.56-10.56) had a higher risk of relapse after ending CSC services. Cannabis use at last contact was also associated with lower rates of outpatient psychiatric follow-up (aOR = 0.32, 95 % CI 0.12-0.94), while CSC duration in months had a small positive association with post-CSC psychiatric follow-up. There were no differences in relapse or follow-up by race or ethnicity, primary diagnosis, or medication usage.

CONCLUSIONS

Prior relapse during CSC predicted relapse in the 12 months after ending CSC services, but not outpatient follow up. Cannabis use predicted both a higher rate of relapse and a lower rate of follow up after ending services. There were no differences by race or ethnicity in our sample, suggesting that once individuals engaged in FEP care there were no evident disparities in the observed outcomes.

The effect of duration of untreated psychosis (DUP) on the risk for hospitalization after admission to a first episode service

Engagement with a first episode-psychosis service (FES) reduces the risk of psychiatric hospitalization. However, the role of the duration of untreated psychosis (DUP) in impacting this outcome is disputed. This study aimed to examine whether DUP was an effect modifier of the post-FES reduction of risk of hospitalization, and to explore associations between patients' characteristics and hospitalization post-FES. Individuals aged 16-35 with recent onset (< 3 years) of non-affective psychosis, admitted to the Program for Specialized Treatment Early in Psychosis (STEP), a FES serving the Greater New Haven area, Connecticut, between 2014 and 2019 were included (N = 189). Medical records were queried from 2013 through 2020 for number and duration of psychiatric hospitalizations. Poisson regression models were used to estimate incidence rate ratios for hospitalization rates across all explanatory variables. Negative binomial regression was used to compare the length of stay (LOS) before vs after STEP enrollment. STEP admission was associated with a significant 90 % reduction in the frequency and duration of hospitalizations. This effect was moderated by DUP: with 30-day prolongations in components of DUP (supply, demand, and total) there was less reduction in hospitalizations and LOS after FES enrollment (p < .0001). Only DUP supply (time from first antipsychotic use to STEP admission) differentiated those who were hospitalized during the first year after STEP enrollment from those who were not (median: 35 vs. 15 weeks, p = .003). To fully harness the positive impact of FES on hospitalization, a detailed effort should be pursued to reduce all DUP components.

What happens after early intervention in first-episode psychosis? Limitations of existing service models and an agenda for the future

PURPOSE OF REVIEW

Early intervention in first-episode psychosis (FEP) improves symptomatic and functional outcomes while programs last. However, these gains may not be sustained over time and not all individuals benefit equally from such programs. This review examines the efficacy of FEP programs, as well as step-down practices and long-term outcomes to identify ways to extend the gains made in FEP programs.

RECENT FINDINGS

FEP programs improve outcomes while services last, but effects diminish over time. Step-down and discharge practices vary widely with little randomized evidence guiding practice. Extending the duration of FEP programs for all does not consistently improve outcomes, but there is some encouraging evidence that targeted psychosocial interventions after program end may extend symptomatic and functional benefits. Members of marginalized groups and individuals with poorer outcomes during the FEP period may benefit from further specialized intervention after FEP.

SUMMARY

Step down practices from FEP programs should be structured and tailored to individual needs, and benefit from sustained connections to community resources. Psychosocial interventions like social skills training, peer support, and supported education and employment may help extend the benefit of FEP programs after more intensive services end.