Graduate Thesis Or Dissertation
 

The Effect of Provider Type and Patient-Sharing Networks on Utilization of Mental Health Care in Oregon

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https://ir.library.oregonstate.edu/concern/graduate_thesis_or_dissertations/nc580v694

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  • Unmet healthcare needs and/or delays in needed care are widespread among patients with serious mental illness (SMI). Mental healthcare delivery has changed dramatically over the last two decades. Although access to mental health specialists remains challenging, mental healthcare is now increasingly provided in primary care settings. However, it is unclear how the role of different providers and their relationships with other providers contributes to and affects mental health care, especially given that patients with SMI often experience care fragmentation in both medical and behavioral care provision. This dissertation, consisting of two studies, examined the association between provider factors and mental healthcare utilization by patients with SMI. In addition, this research investigated whether the providers’ factors exhibited heterogeneous effects on mental healthcare utilization by the type of health plans and urban/rural residence. Using Oregon All Payer All Claims data, I identified 174,569 patients who had a non-primary or primary diagnosis with SMI; initially visited a primary care physician (PCP), nurse practitioner (NP), or mental health provider (MHP) as an outpatient; and provided 12 months of follow-up data. Using social network analysis (SNA), I identified networks of providers linked by shared patients. Adjusted degree, which reflects the average workload of contacting other providers when a provider treats a patient, from SNA measures was constructed. It was used as a proxy to represent a provider’s relationship with other providers in this study. Multivariate regression analysis was used to estimate associations between provider type, adjusted degree, and utilization, including mental health-related outpatient visits (MHOVs), inpatient visits (MIVs), and ED visits (MHEDVs) within a year following a patient’s first MHOV. This study found that patients who firstly visited an MHP or NP in their first MHOV were associated with more MHOVs compared to patients who firstly visited a PCP in their first MHOV. There was a slightly lower probability of having an MHEDV within a year after the patient’s first MHOV if the patient’s mental health gatekeeper was an MHP compared to those whose mental health gatekeeper was a PCP. A higher value in adjusted degree of mental health gatekeeper was associated with more MHOVs and a higher likelihood of having an MIV or MHEDV within a year following the patient’s first MHOV. Having a PCP or NP as mental health gatekeeper was associated with an amplified effect of adjusted degree on mental healthcare utilization. Next, using a subsample of Study 1, Study 2 focused on those patients who initially visited a primary care provider (including PCP and NP) and ever visited a psychiatrist subsequently at any point within a year. I examined whether the timing of referral to a psychiatrist and the psychiatrist’s relationship with other providers were associated with mental healthcare utilization for patients with SMI. This study found that higher value in adjusted degree of the psychiatrist was associated with more MHOVs, a slightly higher likelihood of having an MHEDV and a negligibly increased likelihood of having an MIV within a year following the patient’s first MHOV to the psychiatrist. An increased referral time interval to the first psychiatrist was associated with fewer MHOVs and a negligibly reduced likelihood of having a MIV or MHEDV within a year following the patient’s first MHOV to the psychiatrist. The association between the referral time to a psychiatrist and the number of MHOVs differed by the type of health plan and urban/rural residence. These findings highlighted that provider-related factors may explain a major proportion of variations in mental healthcare utilization for patients with SMI. Compared to those providers in the primary care setting, MHP as a patient’s mental health gatekeeper seems to be more actively engaged with the patient’s treatment and is associated with more outpatient visits and less intensive care use in the first year after patients were diagnosed with SMI. A longer referral time to a psychiatrist was associated with less mental healthcare utilization, which may imply difficulty in access to mental care time or relatively mild mental dysfunctions. A provider with a high adjusted degree who shared patient care with a wider set of colleagues may have greater difficulty in exchanging or consolidating his/her patients’ medical information, thus associating with more utilization of mental healthcare of his/her patients with SMI. Further research needs to identify the factors that drive patients with SMI to visit a different provider initially as well as the factors contributing to these patients being treated differently by providers. Validation and development of care fragmentation measures from SNA are needed to inform policy and practice.
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  • Pending Publication
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  • 2022-07-09 to 2023-02-09

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