Predictors and Outcomes of Post-Discharge Service Use Among Youth Psychiatrically Hospitalized for the First Time

Purpose: Decreases in the average length of stay in inpatient psychiatric settings have in part been based on the assumption that community-based aftercare services are effective and accessible. Post-discharge mental health services presumably provide continuity of care, support gains made in the inpatient setting, and are meant to reduce the likelihood of rehospitalization. While many youth seem to receive services following an episode in patient psychiatric care, little is known about the types of services received, or the intensity and sequencing of services. This study examined post-discharge specialty and non-specialty mental health service use among a sample of children and adolescents who experienced their first psychiatric hospitalization. It further investigated predictors and outcomes of post-discharge service use.

Methods: Two-hundred study participants were randomly recruited from a sampling frame of over 4500 former child and adolescent patients who were first psychiatrically hospitalized between 1/1/02 and 12/31/05 at a major psychiatric inpatient facility in the Southwest region of the US. The final study sample was 186. Data collection involved two phases. Phase 1 included structured telephone interviews (based on the Child and Adolescent Services Assessment [CASA]) with caregivers of former child/adolescent patients to gather post-discharge services data. Phase 2 involved case abstractions to collect clinical and historical risk factor information. We used negative binomial regression to examine the impact of demographic (gender, race/ethnicity, age at admission), clinical (diagnosis, impairment), and family risk factors (MH history, violence, involvement, insurance) on service use. We further investigated the impact of service use on risk of rehospitalization and subsequent lengths of stay in inpatient psychiatric care, using survival analysis and negative binomial regression, respectively.

Results: Descriptive findings indicate that 28.5% of youth received no post-discharge services of any kind, 36.6% received non-intensive outpatient mental health services, 11.3% received intensive outpatient mental health services, 17.2% received both intensive and non-intensive services and 6.5% of youth received only non-specialty mental health services. Youth with family histories of mental illness received fewer post-discharge services after controlling for salient risk factors. Insurance type was also related to mental health service use. Type of service received was not predicted by any of the covariates; however, the intensity of post-discharge mental health service use (dosage) significantly reduced the likelihood of rehospitalization and also shortened subsequent stays when rehospitalization did occur.

Implications:: Findings from this analysis show that almost three-quarters of youth receive some post-discharge services even though the intensity of these services greatly varies. Few risk factors were significantly related to post-discharge use, and these findings are discussed within the context of available theoretical models of service use utilization. Intensity of services had a greater impact on positive outcomes than receipt of services alone. Findings point to the problems associated with assuring continuity of care for youth with severe emotional and behavioral problems. They also highlight how disconnected inpatient settings are from the provision of post-discharge care, and that despite the availability of evidence-based treatments, the mental health community struggles to deliver effective services to this population.