Continuity and Satisfaction with Psychiatric Services

Continuity of and Satisfaction with Psychiatric Services: A Longitudinal Perspective Before and After Managed Care

Co-investigators: Jonathan Rabinowitz, DSW, Evelyn Bromet, Ph.D., and Joseph Schwartz, Ph.D.

PROJECT GOALS
The impact of managed care on mental health services is a vital and little explored question in the treatment of persons with severe mental illnesses. Proponents of managed care stress the benefits of reducing unnecessary care; opponents are concerned that people may not receive necessary services.

This study is analyzing data from the Suffolk County Mental Health Project, the largest ongoing longitudinal psychiatric epidemiological study in the United States, providing a unique opportunity to explore these questions. The Suffolk County project has been tracking the use of mental health services by individuals receiving psychiatric care since 1989. During this time managed care has played an increasingly prominent role in the delivery of health care in Suffolk County.

The current study focuses on questions relating to treatment and service utilization using a comprehensive array of service variables. The aims of the study differ from the objectives of the parent project by seeking to address the following questions:
    (1) Has the amount of time from the first onset of psychotic symptoms until first treatment changed over time?
    (2) To what extent have numbers and lengths of re-hospitalization changed over time?
    (3) To what extent has the mix of inpatient and outpatient care changed over time?
    (4) To what extent has continuity of care changed;
    (5) To what extent have costs per year of care changed over time?
    (6) To what extent have patients' satisfaction with treatment changed over time?
    (7) To what extent have patients' quality of life changed over time?

RESEARCH ACTIVITIES AND RESULTS
In addition to the data from the Suffolk County Mental Health Project, macro level data on changes in public and private insurance and the health care delivery system have been gathered from state, county and private insurance companies. These data are being used to map changes in the delivery system against changes in care reported by patients. Additionally, information was gathered on macro level changes in clinical outcomes, service use, costs of care and quality of life during the growth of managed care programs. Outcomes are being operationalized in terms of re-hospitalization, symptomatology, functioning, services data (type of facility, type of services received and frequency of utilization), patient satisfaction, compliance with care, medication side effects, costs and quality of life. Symptomatology, functioning and quality of life are measured using a battery of self-report and rating scales. Consumer satisfaction is measured using a satisfaction-with-care index developed by the Suffolk County Mental Health Project. Multivariate analyses control for demographic factors (ethnicity, gender, age, social class), pre-morbid functioning, diagnosis and intelligence. Continuity of care scales are being developed based on the project's extensive mental health and substance abuse services data.

Data on insurance type (HMO, Preferred Provider, Fee for Service, Medicaid-Medicare, VA) were collected for the sample from multiple sources (hospital admission and discharge records, hospital billing records, respondent and significant-other responses to a questionnaire on insurance, employment history and interviewer's notes).

A procedure was developed and implemented to arrive at insurance type at time of first hospitalization and for the four follow-up years currently covered by the study, by combining information from all available sources. Reasons given for patients' not having insurance were also coded.

Insurance type variables have been added to the active data history.

SIGNIFICANCE OF FINDINGS/POLICY IMPLICATIONS
By enhancing the data set of this study with detailed data on insurance of subjects at multiple time periods, the impact of many health policy reforms on service utilization and outcomes can be examined. Such studies might include analyses of policy changes having to do with the penetration of managed care in the area or the implementation of mental health parity legislation.

Publication:

Rabinowitz, J., Bromet, E.J, Lavelle, J., Carlson, G., Kovasznay, B., Schwartz, J.E. Prevalence and severity of substance use disorders and onset of psychosis in first-admission psychotic patients. Psychological Medicine, 28:6, Nov. 1988, pp. 1411-19.

Project completed.

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