Written by Laura Murphy
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Among Medicaid-enrolled children, rates of outpatient follow-up after discharge from the ED for a mental health (MH) diagnosis are low, particularly for children who are Black, have fee-for-service (vs. capitated) coverage, and without previous outpatient mental health visits.
Why does this matter?
As number of ED visits for mental health conditions among children are increasing, access to outpatient follow-up care has become increasingly important. This study highlights important statistics regarding follow-up MH care among pediatric patients enrolled in Medicaid as well as disparities in outpatient follow-up care with regards to race as well as payor type.
The kids are not alright
This was a retrospective cohort study of 28,551 children from ages 6-17 years old enrolled in Medicaid in 11 de-identified states with at least one MH ED discharge from January 2018 to June 2019. Children with no mental health or substance use coverage were excluded as were children without continuous Medicaid enrollment for 6 months after index ED visit. The most common diagnoses were depressive disorders (39.1%), disruptive, impulse control and conduct disorders (25%), and trauma and stressor-related disorders (14.2%).
After discharge from index ED visit, only 31.2% of children had follow-up within 7 days and 55.8% had follow-up within 30 days. Non-Hispanic Black children were less likely to have follow-up at both 7 and 30 days (aOR 0.89, 95% CI 0.84-0.94;0.78, 95% CI, 0.74-0.83) compared to non-Hispanic White children. In addition, children with fee-for-service insurance were less likely to have follow up compared to patients with capitated insurance (aOR 0.72, 95% CI 0.68-0.77 at 7 days; 0.83, 9% CI 0.79-0.88 at 30 days). Finally, rates of follow up visits after index MH ED visits increased as the number of outpatient MH visits in the previous year increased, which may represent having access to an established MH provider or ambulatory MH care.
The rate of return acute care encounters was 6.5%, 12.8%, and 26.5% within 7 days, 30 days, and 6 months, respectively. Of these return encounters, 49.7% were ED discharges and 50.3% were hospitalizations. These high return rates suggest that EDs may not be effective sources of care for management of MH crises for children. Interestingly, timely follow up was associated with reduced returns within 5 days of ED discharge, but an increased risk of return after 5 days. This aligns with previous studies and may be partially explained by clinical severity or unmeasured markers of a family’s likelihood to seek care.
This study highlights the need for targeted interventions to ensure pediatric patients are receiving adequate MH follow up care, with particular attention to reducing barriers to outpatient MH care for Black children.
Source
Follow-up After Pediatric Mental Health Emergency Visits. Pediatrics. 2023 Mar 1;151(3):e2022057383. doi: 10.1542/peds.2022-057383.
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