INPATIENT PSYCHIATRIC CARE FOR CHILDREN & YOUTH

INPATIENT PSYCHIATRIC CARE FOR CHILDREN & YOUTH

AUGUST 2010

PRECIPITANTS & PREDICTORS OF ADMISSIONS & READMISSIONS

Becci Akin, PhD, Research Associate Stephanie Bryson, PhD, Research Associate Sachiko Gomi, PhD Student, Graduate Research Assistant Terry Moore, MSW, Principal Investigator Erica Parkinson-Arnold, BA, Program Assistant Lauren Tullis, BSW, Research Assistant

This project was supported through a contract with the Kansas Department of Social and Rehabilitation Services Division of Disability and Behavioral Health Services

Office of Child Welfare and Children's Mental Health Twente Hall 1545 Lilac Lane Lawrence, KS 660044-3184 Tel: (785) 864-4720 Fax: (785) 830-8026 Website:

EXECUTIVE SUMMARY ........................................................................................................................................... I

CHAPTER 1: INTRODUCTION ................................................................................................................................. 1

PROBLEM STATEMENT.....................................................................................................................................................1 BACKGROUND ON THE KANSAS PUBLIC MENTAL HEALTH SYSTEM ............................................................................................3 OVERVIEW OF REPORT.....................................................................................................................................................4

CHAPTER 2: LITERATURE REVIEW.......................................................................................................................... 5

FINDINGS FROM STUDIES ON ADMISSION TO INPATIENT PSYCHIATRIC CARE ...............................................................................5 Demographic Variables..........................................................................................................................................5 Diagnosis/Clinical Need Variables .........................................................................................................................6 Service Related Variables.......................................................................................................................................7 Parent/Family Variables ........................................................................................................................................7

FINDINGS FROM STUDIES ON READMISSIONS FROM INPATIENT PSYCHIATRIC CARE......................................................................8 Demographic Variables..........................................................................................................................................8 Diagnosis/Clinical Need Variables .........................................................................................................................9 Service Related Variables.....................................................................................................................................10 Parent/Family Variables ......................................................................................................................................11

LIMITATIONS & GAPS IN THE LITERATURE ..........................................................................................................................12 INTERNET SEARCH OF STATE INITIATIVES ...........................................................................................................................13

CHAPTER 3: METHODS ........................................................................................................................................ 15

STUDY PURPOSE AND RESEARCH QUESTIONS .....................................................................................................................15 QUANTITATIVE ANALYSES...............................................................................................................................................15

Study Population..................................................................................................................................................15 Data Collection and Preparation .........................................................................................................................16 Variables ..............................................................................................................................................................17 Data Analyses ......................................................................................................................................................20 QUALITATIVE ANALYSES .................................................................................................................................................22 Study Population..................................................................................................................................................22 Data Collection and Preparation .........................................................................................................................22 Data Analyses ......................................................................................................................................................24 STUDY STRENGTHS AND LIMITATIONS ...............................................................................................................................24

CHAPTER 4: MAJOR FINDINGS FROM QUANTITATIVE ANALYSES ........................................................................ 27

SAMPLE CHARACTERISTICS..............................................................................................................................................27 ADMISSIONS TO INPATIENT PSYCHIATRIC CARE IN KANSAS ....................................................................................................30

Recent Increases in Admissions ...........................................................................................................................30 Geographic Patterns in Admission Rates .............................................................................................................32 Access to Child Psychiatrists ................................................................................................................................34 Other Population Data and Trends ......................................................................................................................35 ADMISSIONS TO ACUTE INPATIENT CARE ...........................................................................................................................36 Descriptive Data on Admissions to Acute Inpatient.............................................................................................36 Results of Multivariate Logistic Regression for Acute Inpatient Admissions .......................................................37 ADMISSIONS TO PRTFS .................................................................................................................................................43 Descriptive Data on Admissions to PRTFs ............................................................................................................43 Results of Multivariate Logistic Regression for PRTF Admissions ........................................................................45 READMISSIONS FROM INPATIENT PSYCHIATRIC CARE IN KANSAS ............................................................................................48

READMISSIONS FROM ACUTE INPATIENT CARE ...................................................................................................................51 Descriptive Data on Readmissions from Acute Inpatient Care ............................................................................51 Results of Multivariate Survival Analyses Model for Readmissions from Acute Inpatient Care ..........................53

READMISSIONS FROM PRTFS..........................................................................................................................................57 Descriptive Data on Readmissions from PRTFs....................................................................................................57 Results of Multivariate Survival Analyses Model for Readmissions from PRTFs..................................................59

CHAPTER 5: MAJOR FINDINGS FROM QUALITATIVE ANALYSES............................................................................ 64 DEMOGRAPHIC, DIAGNOSTIC AND SERVICE CHARACTERISTICS ...............................................................................................64 Summary of Demographic, Diagnostic, and Service Characteristics ...................................................................69 FINDINGS FROM PRE-ADMISSION SCREENS AND CASE REVIEWS.............................................................................................70 FINDINGS FROM INTERVIEWS ..........................................................................................................................................81 Screening Procedures & Adequacy of Screener Training .....................................................................................81 Agency Policy and Practice Regarding Young Children & Hospitalization ...........................................................84 Suggested Systems & Policy Changes ..................................................................................................................92

CHAPTER 6: CONCLUSIONS & RECOMMENDATIONS ........................................................................................... 97 INTRODUCTION ............................................................................................................................................................97 DISCUSSION ................................................................................................................................................................. 97 Summary of Acute Inpatient and PRTF Admission Findings ................................................................................97 Summary of Acute Inpatient and PRTF Readmission Findings...........................................................................103 Summary of Qualitative Findings.......................................................................................................................107 MAJOR CONCERNS .....................................................................................................................................................112 MAJOR RECOMMENDATIONS ........................................................................................................................................117

APPENDIX A QUANTITATIVE DATA .............................................................................................................. 127 APPENDIX B STUDY ADVISORY COMMITTEE ............................................................................................... 146 APPENDIX C MAP OF SRS REGIONS ............................................................................................................. 147 APPENDIX D MAP OF CMHC REGIONS ......................................................................................................... 148 APPENDIX E POPULATION DENSITY MAP .................................................................................................... 149 APPENDIX F LIST OF INPATIENT FACILITIES ................................................................................................. 150 APPENDIX G INTERVIEW SCHEDULE............................................................................................................. 151 APPENDIX H VARIABLES USED IN QUANTITATIVE ANALYSES ....................................................................... 153 APPENDIX I MENTAL HEALTH DIAGNOSES.................................................................................................. 156 APPENDIX J MENTAL HEALTH SERVICE CATEGORIES................................................................................... 163 APPENDIX K CHILDREN'S MENTAL HEALTH INITIATIVES ACROSS THE NATION ............................................ 169 APPENDIX L STATE WEBSITE LINKS ON CHILDREN'S MENTAL HEALTH......................................................... 178 APPENDIX M ANNOTATED BIBLIOGRAPHY OF LITERATURE ON PSYCHIATRIC ADMISSIONS AND READMISSIONS AMONG CHILDREN AND YOUTH ............................................................................................... 182

Table 1. Quantitative Data Sources .............................................................................................................................16 Table 2. Overview of Variables Used for Multivariate Analyses..................................................................................21

Table 3. Sample Characteristics ...................................................................................................................................29 Table 4. Medicaid Admissions By CMHC and Facility Type..........................................................................................33 Table 5. Child Psychiatrists per 100,000 Children By CMHC Catchment Area.............................................................35 Table 6. Bivariate Statistical Significance of Predictor Variables for Acute Inpatient Admissions ..............................37 Table 7. Logistic Regression Model for Acute Inpatient Admissions ...........................................................................42 Table 8. Bivariate Statistical Significance of Predictor Variables for PRTF Admissions ...............................................44 Table 9. Logistic Regression Model for PRTF Admissions ............................................................................................47 Table 10. Readmission Numbers and Percents by Type of Facility..............................................................................48 Table 11. Frequency and Percentages for Types of Facility Readmitted To ................................................................51 Table 12. Bivariate Statistical Significance of Predictor Variables for Readmissions From Acute Inpatient Care .......52 Table 13. Survival Analysis Model for Readmissions from Acute Inpatient Care ........................................................56 Table 14. Bivariate Statistical Significance of Predictor Variables for Readmissions From PRTFs...............................58 Table 15. Survival Analysis Model for Readmissions from PRTFs ................................................................................60 Table 16. Demographic Characteristics, Children 3-5 Admitted/Not Admitted in FY09 .............................................65 Table 17. Diagnostic Characteristics, Children 3-5 Admitted/Not Admitted in FY09 ..................................................66 Table 18. Diagnostic Characteristics, Children 3-5, Hospitalized in FY09 (n=43).........................................................67 Table 19. Service Characteristics, Children 3-5 Admitted/Not Admitted in FY09 .......................................................68 Table 20. Service Characteristics, Children 3-5 Admitted/Not Admitted in FY09 .......................................................69 Table 21. Reasons for Hospitalization from Pre-Admission Screens ...........................................................................70 Table 22. Diagnoses at the Time of Pre-Admission Screening.....................................................................................71 Table 23. Screen Reads vs. Case Reviews ....................................................................................................................72 Table 24. Precipitants of Admission per Chart Review................................................................................................75 Table 25. Summary of Admission Findings with Notes on Existing Studies...............................................................101 Table 26. Summary of Readmission Findings with Notes on Existing Studies ...........................................................105 Table 27. Demographic Data for Acute Inpatient Admissions...................................................................................128 Table 28. Diagnostic Data for Acute Inpatient Admissions........................................................................................129 Table 29. Additional Diagnostic Data on Acute Inpatient Admissions.......................................................................130 Table 30. Service Data for Acute Inpatient Admissions.............................................................................................131 Table 31. Additional Service Data on Acute Inpatient Admissions............................................................................132 Table 32. Demographic Data on PRTF Admissions ....................................................................................................133 Table 33. Diagnostic Data on PRTF Admissions .........................................................................................................134 Table 34. Additional Diagnostic Data on PRTF Admissions........................................................................................135 Table 35. Service Data on PRTF Admissions ..............................................................................................................136 Table 36. Additional Service Data on PRTF Admissions.............................................................................................137 Table 37. Demographic Data By Type of Facility for Readmissions ...........................................................................138

Table 38. Diagnostic Data by Type of Facility for Readmissions ................................................................................139 Table 39. Additional Diagnostic Data by Type of Facility for Readmissions ..............................................................140 Table 40. Service Data by Type of Facility for Readmissions .....................................................................................141 Table 41. Additional Service Data by Type of Facility for Readmissions....................................................................142 Table 42. Demographic Data for Admissions, Comparing Children with a Disability/SSI to Those without Disability/SSI ..............................................................................................................................................................143 Table 43. Diagnostic Data for Admissions, Comparing Children with a Disability/SSI to Those without Disability/SSI ................................................................................................................................................................................... 144 Table 44. Service Data for Admissions, Comparing Children with a Disability/SSI to Those without Disability/SSI ..145 Table 45. Additional Service Data for Admissions, Comparing Children with a Disability/SSI to Those without Disability/SSI ..............................................................................................................................................................145

Figure 1. Conventions for Interpreting Effect Sizes .....................................................................................................22 Figure 2. Number and Percentage of Index Admissions in FY09 By Type of Facility ...................................................30 Figure 3. All Admissions in FY08 and FY09 By Type of Facility.....................................................................................31 Figure 4. Difference in Admissions From FY08 to FY09 By Type of Facility and Age Group ........................................32 Figure 5. Medicaid Admission Rates By CMHC ............................................................................................................34 Figure 6. Overview of Predictor Variables Included in Logistic Regression Analyses ..................................................38 Figure 7. Time from Index Admission to Readmission in 30-Day Increments by Facility Type....................................49 Figure 8. Kansas Readmission Rates Compared to Other Studies' Readmission Rates ...............................................50 Figure 9. Precipitants of Hospitalization......................................................................................................................74 Figure 10. Multiple Hospital Admits, 3-5 Age Group ...................................................................................................80 Figure 11. Multiple Hospital Admissions By Foster Care Status, 3-5 Age Group .........................................................81

The authors are grateful for the funding and support provided by the Department of Social and Rehabilitation Services, Disability and Behavioral Health Services. Several individuals at SRS/DBHS and Kansas Health Solutions were instrumental in providing data and technical support. We wish to express our appreciation for the help provided to us by Becky Ortega, Jim McGill, Tim Meier, Bob Heintzelman, and John Klein. Thanks also to Cheryl Holmes and Liz Crickard for your assistance with sharing data on Kansas demographics, and to Lynda Heimbach for her diligent and timely work preparing numerous data files.

We owe special thanks to all Community Mental Health Center staff--CBS directors; Emergency Services & Crisis coordinators, directors, and screeners; clinical directors; executive directors, and Quality Assurance directors--who graciously assisted with qualitative data collection. This study benefited enormously from the time and expertise of center staff who sat with researchers--sometimes for several hours--and helped to navigate paper and electronic charts. We deeply appreciate your willingness to ensure that researchers gained an accurate understanding of cases and agency policies.

Finally, we want to acknowledge the members of the study's Advisory Committee who generously gave their time. We sincerely thank these individuals for their commitment to improving Kansas children's mental health services and for providing this study with valuable guidance: David Anderson, Eric Atwood, Kathy Byrnes, Randy Callstrom, Brian Dempsey, Shelley Duncan, Bobbie Graff-Hendrixson, Sandy Hashman, Kurtis Marozas, Maggie Myers, Becky Ortega, Jody Patterson, Nahid Shavaki, Dan Stecklein, Erick Vaughn, Amy Wacker, and Janie Yannacito.

Introduction and Background

and state governments have a long history

Children's mental health problems are significant and widespread.1 One in five

of discussing reforms of children's mental health care. Currently, these deliberations

children (0-18) has a diagnosable mental

occur in an environment of rising health

disorder, and approximately one in ten has

care costs and government budget

a mental health problem severe enough to

shortfalls. The paramount challenge is

disrupt daily functioning at home, school,

finding an appropriate balance between

and in the community (New Freedom

institutional and community-based services

Commission on Mental Health, 2003).

so that children's needs can be met and

Children living in low-income households

limited government

are at increased risk for One in five children (0-18) has resources used

mental health problems a diagnosable mental disorder, efficiently. Compounding

and rely heavily on Medicaid for their mental health care (Howell, 2004).

Although more than 3 million children and

and approximately one in ten has a mental health problem severe enough to disrupt daily functioning at home, school, and in the community.

these enduring and complex questions is a lack of uniform, comprehensive data on which administrators and policymakers can rely to

youth receive treatment in a specialty

make effective policy decisions. These

mental health setting each year (SAMSHA,

issues provide the context of the present

2009), researchers have found that 50 to

study.

80% of those in need of mental health

In the fall of 2009, Kansas Department

services do not receive them (Kataoka,

of Social and Rehabilitation Services,

Zhang, & Wells, 2002). Access issues are

Division of Disability and Behavioral Health

also relevant to inpatient treatment.

Services (SRS/DBHS) requested the present

Despite national recognition of the

study. Two interrelated concerns were the

scope and significance of children's mental

impetus: 1) an increase in children's

health needs, children and families face

inpatient psychiatric admissions and 2) the

several persistent barriers. Communities

hospitalization of preschool-aged children.

1 This report will refer to children and adolescents as children. The term "mental health problems," as used by the National Technical Assistance Center for Children's Mental Health (NTACCMH) and the Institute of Medicine (IOM), refers to the broad spectrum of mental problems -- from serious mental illness to problematic behavior -- including mental, emotional and behavioral (MEB) disorders (Institue of Medicine, 2009).

SRS asked University of Kansas, School of Social Welfare (KU SSW) researchers to provide an in-depth analysis of factors potentially related to psychiatric hospitalization among Medicaid-enrolled children in Kansas, and to identify strategies to avert hospitalization.

Study of Inpatient Psychiatric Admissions Among Children and Youth/August 2010 Executive Summary, Page i

Researchers formed an Advisory Committee to provide guidance and expert review of the study's findings. This committee: 1) reviewed preliminary study findings, 2) suggested additional analyses, 3) provided interpretation of findings, and 4) offered expert opinions on recommendations.

Kansas Public Mental Health System Kansas' public mental health system

generally consists of two major service components: outpatient and inpatient treatment. Outpatient treatment is provided by 26 local Community Mental Health Centers (CMHCs) and a network of other approved providers. Inpatient treatment is provided by a number of facilities across Kansas. During fiscal year 2009 (FY09), the period of the current study, children received inpatient

psychiatric care at Larned State Hospital, KVC Star, inpatient psychiatric hospitals, and Psychiatric

During state fiscal year 2009, the period of the current study, children received inpatient psychiatric care at:

Larned State Hospital, KVC Star, Inpatient psychiatric

hospitals,

and Psychiatric Residential Treatment Facilities (PRTFs).

Residential Treatment Facilities (PRTFs).

Kansas public mental health system

utilizes a screening process for all persons

who are Medicaid-eligible or potentially

eligible and seeking inpatient psychiatric

services. The intent of the screening process

is to ensure the most appropriate, least

restrictive level of care for the child,

considering available alternative community

STUDY DESIGN The purpose of this study was to explore factors associated with child psychiatric inpatient admissions and readmissions, and to identify potential strategies for averting admissions and readmissions. A mixed methods research design was used to combine quantitative and qualitative approaches. RESEARCH QUESTIONS 1. What demographic, diagnostic, and service characteristics were associated with psychiatric inpatient admissions

among children and youth 3 to 17 years old? 2. What demographic, diagnostic, and service characteristics were associated with psychiatric inpatient readmissions

among children and youth 3 to 17 years old? 3. What were the key precipitants of psychiatric inpatient admissions for children 3 to 5 years old? 4. What were the key precipitants of psychiatric inpatient readmissions for children 3 to 5 years old? 5. What potential strategies may be used to avert inpatient admission and/or readmission of children and adolescents,

especially among those aged 3 to 5 years old? STUDY POPULATION The study population for the quantitative analyses included all children 3 to 17 years old who were enrolled in Medicaid during state fiscal year 2009 (July 1, 2008 through June 20, 2009). The sample consisted of 178,558 children and youth Medicaid beneficiaries. The qualitative data analyses were conducted on a subgroup of 3-5 year old children who were admitted for inpatient psychiatric care in FY09 (n = 42). DATA COLLECTION Quantitative data were collected from several state administrative databases including Medicaid Management Information System (MMIS) and state's the Inpatient Screening database. Qualitative data were collected from inpatient screening documents, case records, and interviews of CMHC staff.

Study of Inpatient Psychiatric Admissions Among Children and Youth/August 2010 Executive Summary, Page ii

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