The Influence of Individual and Contextual-Level Factors On Continuity of Care for Adults with Schizophrenia

Background and Purpose: Continuity of care is considered to be a critical indicator of quality of care and key to effective management of schizophrenia. For individuals with schizophrenia, good care requires access to a wide variety of medical and non-medical support services, and extensive coordination across providers, funding sources, and service delivery systems (Anderson & Knickman, 2001; Gelber & Dougherty, 2005). Yet services in the de facto mental health system are often fragmented, decentralized, and poorly coordinated, with wide variations in quality of care. The primary aims of this study were to: (1) examine rates of conformance to continuity of care treatment guidelines; and (2) identify individual and community-level factors associated with variations in continuity of care.

Methods: A retrospective cohort design was used to achieve study objectives. The study population included all adults aged 18 to 64 who were diagnosed with schizophrenia and classified as disabled, received two or more outpatient mental health visits during fiscal year 2004, and continuously enrolled in Ohio's Medicaid program during the 1 year follow-up period (N=8,621). Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care system characteristics) were abstracted from Medicaid claims/eligibility files and the Area Resource File. The primary outcome measures captured various dimensions of continuity of care: regularity of care (medication management and outpatient treatment); transitions of care (from inpatient to outpatient); and care coordination (receipt of case management for high users and treatment for dual diagnosis). Hierarchical/multilevel modeling was used to assess the associations between individual and contextual-level variables on continuity of care.

Results: About two-thirds of consumers had at least one medication management or outpatient psychotherapy visit (66% and 68%, respectively). Of those who were hospitalized, less than a fifth (15%) received monthly follow-up within six months after discharge. Sixty-four percent of those who were high users of mental health services received case management visits on a regular basis, while only 3.5% of consumers with co-occurring schizophrenia and substance-abuse disorders received regular treatment for both disorders. In the multivariate models, being African American, homeless, and having a comorbid substance abuse disorder decreased the odds of conformance to continuity of care standards. Of the contextual-level factors examined, living in a county with higher poverty rates, fewer community mental health centers, and/or rural areas negatively impacted the odds of conformance.

Conclusions and Implications: Among Medicaid enrollees with schizophrenia conformance rates for continuity of care are below recommended guidelines and variations are associated with both individual and contextual-level factors. Study findings underscore the need for quality improvement efforts to be directed towards vulnerable subpopulations, particularly racial/ethnic minorities and the dually diagnosed and to address contextual-level factors that affect quality of care such as health care supply and socioeconomic constraints.