Datapoints: payer source for emergency room visits by persons with psychiatric disorders

Association of mental health disorders and Medicaid with ED admissions for ambulatory care-sensitive condition conditions

INTRODUCTION

Adult Medicaid enrollees are more likely to have mental health disorders (MHDs) than privately insured patients and also have high rates of emergency department (ED) visits for ambulatory care-sensitive conditions (ACSCs). We aimed to evaluate the association of MHD and insurance type with ED admissions for ACSC in the United States.

METHODS

We conducted a cross-sectional study of ED visits made by adults aged 18 to 64 years using the corrected 2011 National Emergency Department Survey. Using multivariable logistic regression analysis, we controlled for sociodemographics and clinical variables to determine the association between insurance type, MHD, Medicaid, and MHD (as an interaction variable) and ED admissions for ACSC.

RESULTS

There were 131 million ED visits in 2011; after exclusions, 1.4 million admissions were included in our study. Of all ED visits, 44.7% had an MHD, of which 49.9% were covered by Medicaid and 38.1% were covered by private insurance. A total of 32.6% (95% confidence interval, 32.5%-32.7%) of ED admissions were for an ACSC. Medicaid-covered ED visits were more likely to result in ACSC hospital admission (odds ratio, 1.32; 95% confidence interval, 1.30-1.35) compared with visits covered by private insurance. Among patients with MHD, those with Medicaid insurance had 1.6 times the odds of ACSC admission compared with those privately insured.

CONCLUSION

Among all ED admissions, patients covered by Medicaid are more likely to be admitted for an ACSC when compared with those covered by private insurance, with a larger association being present among patients with MHD comorbidities.

Use of critical access hospital emergency rooms by patients with mental health symptoms

CONTEXT

National data demonstrate that mental health (MH) visits to the emergency room (ER) comprise a small, but not inconsequential, proportion of all visits; however, we lack a rural picture of this issue.

PURPOSE

This study investigates the use of critical access hospital (CAH) ERs by patients with MH problems to understand the role these facilities play in rural MH needs and the challenges they face.

METHODS

Primary data were collected through the combination of a telephone survey and ER visit logs. Our sampling frame was the universe of CAHs at the time the survey was fielded.

KEY FINDINGS

About 43% of CAHs surveyed operate in communities with no MH services, while 9.4% of all logged visits were by patients identified as having some type of MH problem. The most common problems identified were affective disorders, substance abuse, anxiety, and psychotic disorders. Only 32% of CAHs have access to on-site detoxification and 2% have inpatient psychiatric services, meaning that patients in need of these services typically must leave their communities to gain treatment.

CONCLUSIONS

The lack of community resources may impact CAHs' ability to assist patients with MH problems. Among those with a primary MH condition, 21% left the ER with no or unknown treatment, as did 51% of patients whose MH condition was secondary to their emergent problem. Patients in need of detoxification or inpatient psychiatric services often must travel over an hour to obtain these services, potentially creating significant issues for themselves and their families.

The experience of gatekeeping: a psychiatric nurse in an emergency department

Emergency departments are increasingly identified as the entry point to mental health services. In the hope of facilitating the flow of psychiatric patients through a general hospital's emergency department, experienced psychiatric nurses were asked to participate in a pilot project in a general hospital in Canada. This paper is a reflection of one emergency psychiatric nurse's (EPN) experience of her role being transformed into that of a gatekeeper. The notion of "gatekeeper" as a metaphor highlights "keeping psychiatric patients out" of an already strained emergency system. As a means to balance fiscal demands with patient care, the EPN inadvertently served to obscure entry for patients with mental illness who were seeking emergency services.