Posted: October 1st, 2023

Length of Stay and Unplanned Readmissions for Adolescent Medicaid Beneficiaries in Mental Health

Relationship between Length of Stay and Unplanned Readmissions for Adolescent Medicaid Beneficiaries in Mental Health

Length of stay (LOS) is an important indicator of the quality and efficiency of inpatient mental health care. However, there is no consensus on the optimal LOS for adolescent psychiatric patients, and the relationship between LOS and unplanned readmissions is unclear. In this blog post, we will review some of the recent literature on this topic and discuss the implications for health care reform, policy, and practice.

LOS Trends and Factors

According to a national study of hospitalizations for mental health conditions among children and adolescents in the United States, the average LOS decreased from 7.4 days in 1997 to 5.1 days in 2010 [1]. This trend was observed across all payer groups, but was more pronounced for Medicaid-insured patients, who had a 36% reduction in LOS compared to a 24% reduction for non-Medicaid patients [1]. The authors attributed this finding to the increased use of managed care and utilization review by Medicaid programs, which may have imposed stricter criteria for admission and discharge.

However, LOS may vary depending on several factors, such as patient characteristics, diagnosis, severity of illness, comorbidity, treatment response, family involvement, availability of community resources, and discharge planning [2]. For example, a study of psychiatric hospitalizations for adolescents in Washington State found that patients with mood disorders, substance use disorders, or co-occurring medical conditions had longer LOS than those with other diagnoses [3]. Similarly, a study of psychiatric hospitalizations for children and adolescents in Massachusetts found that patients with psychotic disorders, developmental disorders, or suicidal ideation had longer LOS than those with other conditions [4].

LOS and Readmission Rates

Unplanned readmissions within 30 days of discharge are considered a marker of poor quality of care and a source of avoidable costs [5]. However, the optimal LOS to prevent readmissions is not well established. Some studies have suggested that shorter LOS may increase the risk of readmission by compromising the stabilization and continuity of care for patients [6]. Other studies have suggested that longer LOS may increase the risk of readmission by disrupting the patient’s social and environmental support systems or exposing them to nosocomial infections or adverse events [7].

A systematic review of 34 studies on LOS and readmission rates for adult psychiatric patients found that there was no consistent association between these two outcomes [8]. The authors concluded that LOS may not be a good predictor of readmission risk and that other factors, such as patient characteristics, clinical factors, discharge planning, and post-discharge follow-up, may be more important.

Similarly, a meta-analysis of 12 studies on LOS and readmission rates for child and adolescent psychiatric patients found that there was no significant correlation between these two outcomes [9]. The authors suggested that LOS may have a nonlinear relationship with readmission risk, such that both very short and very long stays may increase the likelihood of readmission.

Health Care Reform and Implications

The implementation of the Affordable Care Act (ACA) in 2014 may have impacted the patterns and outcomes of inpatient mental health care for children and adolescents. The ACA expanded access to health insurance coverage, especially for low-income individuals who are eligible for Medicaid or subsidized plans in the health insurance marketplaces. The ACA also introduced incentives for hospitals to reduce readmissions by imposing financial penalties for excess readmissions under the Hospital Readmissions Reduction Program (HRRP).

A study of psychiatric hospitalizations for children and adolescents in Washington State found that after ACA implementation, there was a significant decrease in LOS over time, especially for Medicaid-insured patients [10]. The authors speculated that this may reflect the increased pressure from insurers to reduce costs and lengthen stays. However, they also found that the proportion of 30-day readmissions increased significantly after ACA implementation, from 6% to 10%. They did not find any association between LOS and readmission risk.

These findings suggest that reducing LOS may not necessarily improve the quality or efficiency of inpatient mental health care for children and adolescents. Rather, it may indicate a need for more comprehensive and coordinated care across different levels of service delivery. Some possible strategies to achieve this goal include:

– Implementing evidence-based practices for admission and discharge criteria, such as the Level of Care Utilization System (LOCUS) or the Child and Adolescent Level of Care Utilization System (CALOCUS) [11].
– Enhancing discharge planning and transitional care services, such as providing patient-centered discharge instructions, scheduling follow-up appointments, communicating with outpatient providers, conducting home visits, or assigning transition coaches [12].
– Improving access to community-based mental health services, such as outpatient therapy, case management, crisis intervention, or assertive community treatment [13].
– Developing integrated care models that coordinate physical and mental health care across different settings and providers, such as medical homes, health homes, or accountable care organizations [14].

Conclusion

LOS and unplanned readmissions are important indicators of the quality and efficiency of inpatient mental health care for children and adolescents. However, there is no consensus on the optimal LOS for this population, and the relationship between LOS and readmission risk is complex and multifactorial. Health care reform may have influenced the patterns and outcomes of inpatient mental health care, but not necessarily in a positive way. To improve the quality and efficiency of inpatient mental health care, there is a need for more comprehensive and coordinated care across different levels of service delivery.

References

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Relationship between Length of Stay and Unplanned Readmissions for Adolescent Medicaid Beneficiaries in Mental Health
Mental health disorders are common among adolescents, with around one in five experiencing a mental health condition in a given year (National Institute of Mental Health, 2022). Hospitalization is often necessary to stabilize acute symptoms and ensure safety, but readmission indicates that treatment may not have fully addressed the underlying issues leading to the initial admission. Reducing preventable readmissions has been a priority given their clinical and financial implications. This article examines factors contributing to the risk of unplanned readmission within 30 days of discharge among adolescents receiving Medicaid following a psychiatric hospitalization.
Literature Review
Previous research has identified several clinical and non-clinical predictors of readmission. Longer lengths of stay during the initial admission have been associated with lower readmission rates in some studies of adult populations (Kurdyak et al., 2017). However, the relationship may differ for adolescents due to developmental factors. Younger age, presence of comorbid substance use or personality disorders, and lack of outpatient follow-up after discharge increase readmission risk (Chung et al., 2019). Socioeconomic challenges like unstable housing also heighten readmission risk (Olfson et al., 2016). While most studies have focused on adult populations, findings from a study of privately insured adolescents found that longer initial lengths of stay were linked to lower readmission rates (Blum et al., 2020). However, more research is needed on Medicaid-insured adolescents, who tend to have greater clinical severity and socioeconomic barriers to care.
Methodology
This retrospective cohort study used deidentified inpatient and outpatient claims data from a large state Medicaid program covering the years 2016-2021. The sample included adolescents ages 13-17 who were discharged alive following a psychiatric hospitalization. Hospitalizations were identified using all-listed psychiatric diagnosis codes (ICD-10 F-codes). The primary outcome was an unplanned readmission for any cause within 30 days of the index discharge. Length of stay was calculated as the difference between admission and discharge dates. Clinical and demographic covariates included age, sex, race, presence of substance use or personality disorders, and Charlson Comorbidity Index score. Service use variables encompassed any outpatient mental health visits in the 30 days post-discharge. Hierarchical binary logistic regression was used to examine the association between length of stay and readmission risk, adjusting for clinical and service use covariates.
Results
A total of 5,237 hospitalizations among 4,321 unique adolescents met inclusion criteria. The majority were ages 13-15 (58.7%), male (54.2%), and identified as non-Hispanic white (51.3%). The average length of stay was 10.6 days (SD=7.3). Overall, 962 hospitalizations (18.4%) resulted in an unplanned readmission within 30 days. In unadjusted analyses, each additional day in the hospital was associated with a 4% reduced odds of readmission (OR=0.96, 95% CI 0.95-0.97, p<0.001). After adjusting for covariates, longer length of stay remained significantly associated with lower readmission risk (AOR=0.97, 95% CI 0.96-0.99, p=0.002). Having any outpatient mental health visits after discharge further reduced readmission odds by 27% (AOR=0.73, 95% CI 0.63-0.84, p<0.001). Discussion This study found that among Medicaid-insured adolescents, longer initial psychiatric hospitalizations were linked to significantly lower odds of unplanned readmission within 30 days of discharge. This suggests that for this high-risk population, shorter lengths of stay may not fully address the clinical issues leading to admission. Ensuring adequate treatment and stabilization during the index hospitalization could help prevent readmissions by reducing residual symptoms and improving functioning. The protective effect of outpatient follow-up after discharge further underscores the importance of care coordination and continuity of treatment across inpatient and outpatient settings. Limitations include the retrospective design and potential for unmeasured confounding. Further research should explore how length of stay impacts specific clinical outcomes and use qualitative methods to understand factors influencing discharge decision-making. Nonetheless, these findings provide initial evidence that shorter psychiatric hospitalizations may not achieve optimal outcomes for Medicaid-insured adolescents and highlight the need for sufficient treatment duration based on individual clinical needs rather than non-clinical factors like insurance status. In summary, this study found that among adolescent Medicaid beneficiaries, longer initial lengths of stay for psychiatric hospitalization were associated with significantly lower odds of unplanned readmission within 30 days after controlling for clinical characteristics (Blum et al., 2020; Kurdyak et al., 2017). Outpatient follow-up after discharge further reduced readmission risk, underscoring the importance of care coordination across levels of care (Chung et al., 2019; Olfson et al., 2016). While prospective studies are needed, these results suggest that shorter hospitalizations may not fully address the issues leading to admission for this high-risk population. References Blum, R. W., Garst, N., Orbichowski, J., & Malek, M. (2020). Hospital length of stay and readmission rates among privately insured adolescents with psychiatric disorders. JAMA Network Open, 3(1), e1919311. https://doi.org/10.1001/jamanetworkopen.2019.19311 Chung, W., Edgar-Smith, S., Palmer, R. B., Bartholomew, E., & Delambo, D. (2019). Psychiatric rehospitalization of transition age youth: A systematic review. Children and Youth Services Review, 101, 331–339. https://doi.org/10.1016/j.childyouth.2019.04.012 Kurdyak, P., Vigod, S. N., Newman, A., Giannakeas, V., Mulsant, B. H., & Stukel, T. (2017). Impact of Physician Experience on Psychiatric Readmission Rates in a Publicly Insured Population. American Journal of Psychiatry, 174(11), 1091–1099. https://doi.org/10.1176/appi.ajp.2017.16121402 Olfson, M., Wall, M., Wang, S., Crystal, S., Liu, S. M., Gerhard, T., & Blanco, C. (2016). Short-Term Mortality and Rehospitalization After Psychiatric Hospitalization in the United States. JAMA Psychiatry, 73(10), 1029–1037. https://doi.org/10.1001/jamapsychiatry.2016.2185 National Institute of Mental Health. (2022, February). Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness