Health Care Utilization of Veterans With Serious Mental Illness
The type of SMI diagnosis predicted total number of outpatient visits, demonstrating that veterans with schizophrenic disorders averaged significantly more outpatient visits per year than did veterans with other SMI diagnoses. Interestingly, results showed that veterans with combat flags averaged significantly fewer outpatient visits than did veterans without flags. This finding is notable, as combat exposure is associated with higher rates of MH diagnoses and relatedly higher service utilization. However, combat veterans with SMI but not posttraumatic stress disorder (PTSD), averaged fewer outpatient visits than did veterans without combat exposure, which was not consistent with earlier findings.28 More research specifically on the effects of combat on veterans with PTSD may help in reconciling these findings. Married veterans averaged significantly fewer outpatient visits per year than did divorced or nevermarried veterans. It may be that social support among married couples is protective in veterans with SMI, or that veterans with SMI are unable to maintain marriages.
Hospitalization Predictors
Several significant predictors of psychiatric hospitalization were noted. Increasing age was negatively related to psychiatric hospitalization. It is possible that older patients with SMI receive other types of care, including board and care homes, or MH intensive case management, in which psychiatric outpatient care is readily provided—reducing the need for psychiatric hospitalization. In addition, married veterans were significantly less likely than were divorced and never-married veterans to have been hospitalized. It is possible that being married is protective for MH and physical health or that being unhealthy is a risk factor for divorce.
The type of SMI diagnosis also significantly predicted hospitalization. Having received specific types of services, including residential MH treatment and ancillary services, was a significant predictor of the total number of psychiatric hospitalizations. Last, having a combat flag negatively predicted psychiatric hospitalization—incongruent with earlier findings.24 These results suggest a profile of a veteran who likely could benefit either from a targeted intervention or from having ready access to a social worker.
Improved understanding of service utilization is vital to providing care to returning veterans. Mental disorders are very common among recent OEF, OIF, and Operation New Dawn veterans.29 As the rate of MH diagnoses climbs, the cost of providing health care grows exponentially. The cost of providing care to veterans with SMI can be addressed by identifying veteran-specific factors to provide intensive outreach and prevent costly hospitalization.
Limitations
The results of this study should be interpreted in light of several limitations. It is plausible that at least some veterans received health care services outside the VA, but non-VA data were not included in this study. Subsequent studies should include a group of veterans with SMI and a control group of veterans without SMI so that patterns of hospitalization and utilization rates can be compared. Also, the present study did not include data on missed appointments, an important variable in service utilization.
Missed appointments may suggest lack of follow-through with regular outpatient services, placing patients at risk for emergency services that require hospitalization. Veterans who had a single consultation were excluded in an effort to examine service utilization patterns of established patients. In future studies, including these patients could be informative in identifying specific patterns in this subpopulation. Fifth, PTSD was excluded from this study in order to identify utilization differences for veterans without PTSD.
Conclusion
Results of this study indicate that special attention should be given to veterans’ demographic and clinical factors, including age, sex, combat flags, marital status, and SMI diagnosis. Through identification of and outreach regarding these veteran-specific factors, it may be possible to use targeted interventions to reduce the need for inpatient hospitalization of veterans with chronic mental illness. Historically, the emphasis on access and outpatient care within the VA health care system drastically reduced the number of inpatient MH days.30 This outcome underscores the importance of outpatient services and suggests that targeted outpatient care can further reduce the need for inpatient MH care. Veterans with these outlined risk factors may benefit from implementation of early preventive measures.
