Sample and data collection
The purpose of the diagnostic assessment was to inform and improve care for patients enrolled in the Camden Coalition’s care management intervention. The care management intervention served individuals with a pattern of high hospital use who also demonstrated considerable social and medical complexity. The intervention sought to include patients whose hospital use may be mitigatable through care management.
To identify patients for the intervention, the Camden Coalition’s triage system incorporated a combination of Admit-Discharge-Transfer feeds and Electronic Medical Records (EMRs) from three local hospital systems and used both objective and subjective criteria. Patients who were assessed fit the eligibility criteria for the intervention: they were age 18–80; had health insurance coverage at intervention enrollment; had been hospitalized at least twice in the six months prior to enrollment; had two or more chronic conditions as documented in the EMR’s History and Physical Examination Write-Up from hospital admission, or past medical history from inpatient or outpatient encounter notes; and showed three or more “vulnerabilities” such as documented mental health comorbidity, evidence of difficulty accessing services, homelessness, active drug use, lack of social support, and/or taking more than five medications. Individuals were excluded from the intervention if their hospital admissions were unlikely to have been avoided, such as those related to oncology, planned surgical procedure (e.g. bariatric surgery), acute conditions without other complicating factors (e.g. appendicitis), and complications of a progressive chronic disease with limited treatments (e.g. multiple sclerosis or ALS). Individuals were also excluded if their index admissions were mental health-related only with no co-morbid medical conditions. Enrolled patients that presented with suspected behavioral health needs, or with self-reported behavioral health needs, were referred for a comprehensive behavioral health assessment by their care team.
Between September 2014 and January 2017, 225 enrolled patients were referred for assessment, of which 195 (87%) were available and agreed to be assessed for psychiatric disorders, substance use disorders, and experiences such as trauma and housing instability. The 195 patients who were assessed accounted for 38% of the patients active on the Camden Coalition’s care management panel at any point between September 2014 and January 2017. A bilingual Licensed Clinical Psychologist conducted face-to-face diagnostic assessments during home visits, in the community, or at patients’ appointments with other care providers. The psychologist explained the purpose of the assessment to patients who all spoke English and/or Spanish and who provided verbal consent prior to beginning the assessment. Not all patients who were assessed met criteria for a psychiatric or substance use disorder, but all are included in this study.
Measures
Multiaxial evaluation
Data were collected using a comprehensive behavioral health assessment leading to a multiaxial evaluation with diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [22]. Each patient was assessed for psychiatric diagnoses, substance use disorders, and cigarette smoking. Psychiatric diagnoses included mood disorders (e.g., bipolar, depressive, dysthymic, unspecified), anxiety disorders (e.g., generalized anxiety, panic, posttraumatic stress), psychotic disorders (e.g., schizophrenia), and personality disorders (e.g. borderline personality disorder). Substance use disorders included diagnoses related to abuse, dependence, and remission from substances, including alcohol, cocaine, opioids, cannabis, sedatives/hypnotics, and amphetamines. Patients considered in full and/or partial remission either met none of the criteria or met only part, but not all, of the criteria for abuse or dependence over at least the last 12 months. Nicotine dependence was assessed and analyzed as a separate substance use variable. This was done in concordance with previous studies that have either excluded smoking status when looking at the impact of substance use disorders and emergency department frequent utilization or have analyzed it as a distinct variable [23,24,25]. Patients were also assessed for housing instability and history of trauma based on whether they experienced trauma before and/or after turning 18 years old.
Patients also underwent a Mental Status Examination (MSE), which is commonly used by mental health professionals, primary care doctors, and other clinicians to assess the patient’s behavioral and cognitive functioning to facilitate accurate diagnosis and clinical case formulation [26]. The MSE conducted for this study included direct observation and description of state-of-mind under the domains of appearance, attitude, psychomotor behavior, speech, affect, mood, thought process and content, perception, orientation, memory and concentration, and insight and reliability.
Patient characteristics
Demographic information and other characteristics (e.g., history of mental health treatment, substance use treatment, housing instability) were obtained through self-report and chart reviews.
Health care service utilization
Patients’ hospital records were reviewed to identify the number of hospital admissions and emergency department visits in the six months prior to enrollment in the intervention. Additionally, the records were reviewed to identify the number and type of chronic medical conditions at the time of enrollment, excluding psychiatric and substance use disorders.