Veterans Affairs Health System and Mental Health Treatment Retention among Patients with Serious Mental Illness: Evaluating Accessibility and Availability Barriers

Abstract

Objective. We examine the impact of two dimensions of access--geographic accessibility and availability--on VA health system and mental health treatment retention among patients with serious mental illness (SMI). Methods. Among 156,631 patients in the Veterans Affairs (VA) health care system with schizophrenia or bipolar disorder in fiscal year 1998 (FY98), we used Cox proportional hazards regression to model time to first 12-month gap in health system utilization, and in mental health services utilization, by the end of FY02. Geographic accessibility was operationalized as straight-line distance to nearest VA service site or VA psychiatric service site, respectively. Service availability was assessed using countylevel VA hospital beds and non-VA beds per 1,000 county residents. Patients who died without a prior gap in care were censored.Results. There were 32, 943 patients (21 percent) with a 12-month gap in health system utilization; 65,386 (42 percent) had a 12-month gap in mental health services utilization. Gaps in VA health system utilization were more likely if patients were younger, nonwhite, unmarried, homeless, nonservice-connected, if they had bipolar disorder, less medical morbidity, an inpatient stay in FY98, or if they lived farther from care or in a county with fewer VA inpatient beds. Similar relationships were observed for mental health, however being older, female, and having greater morbidity were associated with increased risks of gaps, and number of VA beds was not significant. Conclusions. Geographic accessibility and resource availability measures were associated with long-term continuity of care among patients with SMI. Increased distance from providers was associated with greater risks of 12-month gaps in health system and mental health services utilization. Lower VA inpatient bed availability was associated with increased risks of gaps in health system utilization. Study findings may inform efforts to improve treatment retention.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

“…Veterans who live farther from VA facilities have been shown to be less likely to visit a VA pharmacy for prescriptions, receive a transplant, have radiation treatment, or use radiology or laboratory services at a VA facility than Veterans who live inside VA service areas or in urban areas French, Bradham, et al, 2012a;Patterson et al, 2014). In interviews, VA health care workers concurred with findings of prior studies reporting that although coordination and continuity of care within VA are generally good, challenges are faced by those who live far away (McCarthy et al, 2007;Skolarus et al, 2013). One study of Veterans with serious mental illness found that those who lived farther from VA had fewer visit days, but more visits per day, suggesting that Veterans who live farther away are more likely to "chain" appointments by scheduling more than one in a single day (McCarthy et al, 2006).…”

Antipsychotic Prescribing Pathways, Polypharmacy, and Clozapine Use in Treatment of Schizophrenia

“…Thus future research should investigate whether organizational characteristics account for some variability in antipsychotic prescribing. For example, differences in availability of resources, staffing, quality improvement capability, program implementation, care coordination, and communication may affect provision of care (26,(31)(32)(33). The organization and provision of care have been shown to vary among VHA mental health programs, which may contribute to the observed variation (31,33).…”

“…Because the VHA has used electronic records for clinical care for many years, readily available administrative data sets can be used to identify and describe longitudinal antipsychotic prescribing pathways. Administrative data have been used extensively in other antipsychotic studies (11,20,(26)(27)(28). …”

Reengaging Veterans With Serious Mental Illness Into Care: Preliminary Results From a National Randomized Trial

“…Two out of every five Veterans with serious mental illness experienced gaps in medical care lasting at least 12 months (4). Improving access to and continuity of health services may mitigate the health risks exacerbated by these gaps in care (3).…”