Behavioral health conditions affect tens of millions of people each year and include mood disorders, anxiety disorders, psychotic disorders, personality disorders, substance use disorders, eating disorders, impulse control disorders, and adjustment disorders — often, a combination of two or more of these.

Behavioral health conditions also are likely to occur with other health problems, adding complexity to these patients’ treatment and potentially influencing outcomes. Patients with behavioral health issues often turn to local emergency departments for treatment and episodic care, contributing to rising health care costs and fragmented care. They also are among populations most likely to have limited access to continuous behavioral health services for long-term condition management.

Because these factors can drive higher readmission rates, reducing preventable readmissions with appropriate and timely care is of paramount concern to the members of Premier and America’s Essential Hospitals.

Work of the Collaboration

Given the challenges hospitals face treating individuals with significant behavioral health needs — and the impact social risk factors have been shown to have on outcomes, in particular, readmissions — Premier and America’s Essential Hospitals sought to better understand the link between behavioral health and readmissions. Following a rigorous study of readmissions data, the collaboration found that behavioral health issues contribute significantly to hospital 30-day readmission rates.

The study sample, from a database maintained by Premier, included patients discharged between April 1, 2015, and March 31, 2018. Using ICD-9 or ICD-10 diagnosis and procedure codes, the study constructed three clinical categories to classify behavioral health (mental health, addiction, and substance abuse). To explore the potential association between those clinical categories and readmissions, the study used the Centers for Medicare & Medicaid Services (CMS) readmission measures for seven conditions (acute myocardial infarction, heart failure, pneumonia, coronary artery bypass graft, chronic obstructive pulmonary disease, total hip and/or knee arthroplasty, and stroke). Readmission was defined as admission to the same facility within 30 days of discharge (i.e., all-cause). Risk adjustment was applied using the CMS preventable readmissions algorithm.

Patients with one of the targeted conditions and a behavioral health diagnosis (the test group) were matched to similar patients without a behavioral health diagnosis (the control group). The final analytic sample consisted of more than 6 million patients in each of the test and control groups, representing more than 800 hospitals. Statistical modeling was used to examine the effect of behavioral health conditions on the risk of 30-day readmission. The model included patient clinical and demographic characteristics (e.g., age, gender, race, severity of illness, discharge status), facility demographic and financial data obtained from hospitals’ CMS Schedule 10 reports, and within–ZIP code radius demographic data from the American Community Survey.

In a comparison of patients with and without one or more behavioral health conditions, coronary artery bypass graft patients with one or more behavioral health conditions showed a 53 percent higher likelihood of readmission. While the research literature has linked clinical depression with suboptimal cardiac intervention outcomes, the collaboration’s work found similar effects for psychotic and personality disorder diagnoses, as well as addiction. Also, these findings were stronger among hospitals that typically serve vulnerable populations, as essential hospitals do. The work of the collaboration suggests that a holistic approach to physical and mental health treatment might improve outcomes for patients and lower readmission rates.

Addressing the Behavioral Health Needs of Vulnerable Patients

Members of America’s Essential Hospitals understand the critical contribution non–health care social services make to achieving effective care transitions and improved outcomes, including reduced readmissions. Patients at essential hospitals are more likely to face social risk factors and comorbid conditions, including behavioral health. As such, essential hospitals are the leaders in creating programs to better integrate behavioral health with primary care, taking a holistic approach to treating patients and improving outcomes while lowering costs. For example, Eskenazi Health, in Indianapolis, offers wraparound services, including behavioral health services, onsite at nine federally qualified health centers. Before 2011, these services were available via referrals to outside providers. A 2018 study of Eskenazi’s colocation of wraparound services associated the program with a 7 percent drop in the expected number of hospitalizations and a 5 percent reduction in emergency department visits during the following year. Researchers estimate these services saved between $8.2 million and $14.2 million from 2011 to 2016. These types of arrangements demonstrate the potential of behavioral health integration to improve outcomes, decrease unnecessary utilization, and control costs.

Essential hospitals have the tools to improve care for patients with multiple comorbidities and to provide clinically effective and culturally competent care for physical and behavioral health. One essential hospital in the NYC Health + Hospitals (NYC H+H) system, in New York, has focused on improving disease-specific outcomes for patients with behavioral health needs.

Kings County Hospital Center’s integrated behavioral health primary care practice seeks to help patients with behavioral health needs better control their diabetes. In 2010, before the start of this innovative primary care practice, patients reported through surveys feelings of embarrassment and a perceived lack of empathy from their primary care providers. Kings County took action, including by building a new primary care practice within its behavioral health building, where patients were accustomed to getting their care and where staff already were proficient at helping patients with mental illness feel at home. Patients received longer appointment times, and newly hired primary care staff were educated in the cultural needs of their patients. Because of these changes, a higher percentage of the practice’s patients showed A1c levels lower than 8, compared with other patients at the hospital and in the NYC H+H system. The practice’s patients also had a no-show rate of 8 percent, compared with 30 percent among patients contemporaneously receiving medical services without behavioral health services.

More Work Remains

Despite the important strides essential hospitals are making to improve access to integrated behavioral health services, more work remains to create, conduct, and evaluate these programs. The joint work of America’s Essential Hospitals and Premier shows that hospitals that disproportionately care for patients with behavioral health needs might experience higher rates of readmission. Essential hospitals often are best suited to create innovative solutions to help the most vulnerable patients, including those with behavioral health needs.

The work of this collaboration validates that behavioral health contributes significantly to hospital readmission rates. Also, as demonstrated by essential hospitals, a holistic approach to physical and behavioral health — through integration of behavioral health in primary care and disease-specific improvement efforts for patients with behavioral health needs — might lead to improved outcomes, reduced utilization, and lowered costs.

This blog post is a collaboration between America’s Essential Hospitals and Premier. Special thanks to Timothy Lowe, PhD, with Premier.