Reprinted from the National Association of State Mental Health Program Directors Weekly Update. Learn more about NASMHPD here.

An Ohio State University Wexner Medical Center study has found that nearly 50 percent of Medicaid-enrolled children and adolescents released from a psychiatric hospital do not receive follow-up care within 7 days of discharge and that a lack of follow-up care results in a higher risk of suicide within the ensuing 180 days.

The study published in JAMA Network Open on August 11 by Cynthia A. Fontanella, Ph.D. and her colleagues, focused on 139,694 child and adolescent Medicaid enrollees in 33 states admitted for psychiatric hospital stays between January 1, 2009 and December 31, 2013.

The objective of the study was to evaluate whether receipt of outpatient care within 7 days of psychiatric hospital discharge is associated with a reduced risk of subsequent suicide among child and adolescent inpatients and to examine factors associated with timely follow-up care. The National Committee on Quality Assurance and the Centers for Medicare & Medicaid Services endorse follow-up within 7 and 30 days after psychiatric hospitalization as quality indicators, but the authors of the study note the rationale is based on clinical consensus rather than empirical evidence. They suggest that, although some studies have examined the association of timely outpatient follow-up with hospital readmission, the association of timely outpatient care with suicide risk after inpatient psychiatric discharge has not been adequately studied.

The 33 states studied were selected based on quality and completeness of managed care claims. The Medicaid claims data included demographic and clinical characteristics, program eligibility, and detailed services information. To identify date and cause of death information, the Medicaid data were linked with data from the National Death Index.

The authors found receiving timely follow-up care was associated with a significantly lower adjusted relative risk of suicide (56 percent) during the 8 to 180 days post-discharge period.

Of the 22 youths in the cohort who died by suicide within 6 months of discharge, eight received a mental health service during the first 7 days after discharge. Among youths who died by suicide, most were male, white, and between the ages of 14 and 18 years. Most were diagnosed with a mood disorder. Of the 22 suicides, 23 percent occurred from 8 to 30 days after discharge, 36 percent occurred from 31 to 90 days after discharge, and 41 percent occurred from 91 to 180 days after discharge.

Youth between the ages of 10 and 18 who were admitted to psychiatric hospitals for up to a month, discharged home, and continuously enrolled in Medicaid throughout the next six months were included in the study. Individuals who were readmitted to psychiatric hospitals were excluded.

About one-third of the cohort were ages 10 to 13 (31.1 percent); the rest (68.9 percent) were older teens. Of the total in the cohort, 47.7 percent were male.

Two-thirds (66.7 percent) were enrolled in Medicaid due to poverty, while 19 percent were enrolled due to disability and 14.3 percent were enrolled through their state’s foster care program. About 77 percent stayed in the hospital for 1 to 7 days.

A single psychiatric diagnosis was recorded for most youths (62.5 percent), but 21.7 percent had two or more comorbid psychiatric conditions. Depression (36.4 percent) and bipolar or mood disorders (33.3 percent) were the most common diagnoses. In the six months before hospitalization, only 6.3 percent of youths had a psychiatric inpatient stay, 15.5 percent had a mental health emergency department visit, and 24.2 percent received outpatient mental health treatment.

Just over half of those in the sample attended a mental health follow-up visit within a week of being discharged (56.5 percent), with children of color less likely to receive follow-up care within 7 days of discharge compared with white children. Compared with white children, it was less likely for African American children, Hispanic children, and children of other racial/ethnic groups to receive follow-up care Also less likely to receive follow-up care: children with comorbid medical conditions, substance abuse, and recent self-harm. Youths with self-harm had 18 percent lower odds of receiving followup care within 7 days and youths with chronic medical conditions had nearly 23 percent lower odds. Youths discharged with a primary diagnosis of depression did not have statistically significant differences from those with schizophrenia or bipolar disorder and other mood disorders in receipt of mental health visits within 7 days.

Foster care youth were more likely to receive follow-up care than children enrolled in Medicaid due to poverty . Children with longer length of stays also tended to be more likely to go on and receive care after discharge.

Teens between 14 and 18 were found by the authors to be less likely to receive follow-up care within a week of discharge than pre-adolescents between the ages of 10 and 13, as were children enrolled in managed care versus fee-for-service care.

The authors of the study note that the findings might not be generalizable to non-Medicaid enrollees or patients with readmissions, and data on some factors like use of psychotropic medication or the nature of linkage services at discharge was not available. In addition, they note that the number of suicides in the cohort was small enough to raise doubts about its statistical relevance.