Kaiser Permanente research offers insights to guide patients to best type of follow-up care
A large proportion of patients (42%) with a first-time diagnosis of a psychotic disorder were diagnosed in the emergency department (ED), according to a Kaiser Permanente research study published in the American Journal of Managed Care. About 46% were diagnosed in outpatient psychiatry clinics, which have more resources to care for patients with new psychosis symptoms.
The study analyzed 1,726 patients aged 15 to 29 with a new diagnosis of a psychotic disorder between 2017 and 2019 in Kaiser Permanente Northern California (KPNC). Psychotic disorders include schizophrenia, delusional disorders, and brief psychosis.
“The emergency department is a critical, and often underrecognized, entry point into mental health care,” said senior author Icelini Stavers-Sosa, MD, a psychiatrist with The Permanente Medical Group and assistant program director for the Kaiser Permanente Northern California Psychiatry Residency Program.
“While outpatient psychiatry provides more comprehensive evaluations and more precise diagnostic clarity, the ED is where many young people first come to attention during an emerging psychotic illness,” Stavers-Sosa added.
The patients studied had diverse racial and ethnic backgrounds and averaged 21 years of age; 43% were female. Of the total, 45.7% received their initial diagnosis of a psychotic disorder in outpatient psychiatry, 42% in the ED, and 3.8% in primary care.
Identifying where patients are diagnosed is important for setting up systems so patients receive appropriate follow-up care, Stavers-Sosa said. It is not straightforward, however; patients seen in emergency care may be told to make an appointment in outpatient psychiatry but may not follow up. “This highlights an opportunity to think creatively about how to help transition these patients to specialty care,” she said.
Patients presenting in the emergency department with severe mental illness and who present a threat to themselves or others may be admitted to inpatient care, but it is harder to ensure follow-up for people with less severe symptoms.
“Psychotic disorders often start in young adulthood,” Stavers-Sosa said. “The ED is a pivotal place to identify young people experiencing psychosis. This is a major opportunity for earlier intervention.”
The number of patients with serious mental health conditions who need intervention but not hospitalization is increasing in the emergency department, said Mamata Kene, MD, a TPMG emergency medicine physician. “Thanks to our integrated care system at Kaiser Permanente, emergency patients benefit from the collaborative care of psychiatrists and therapists who evaluate patients and assist emergency physicians with initiating and continuing medications as well as considering follow up alternatives to hospitalization,” Kene said. “We have a history of being able to innovate and streamline transitions in care between inpatient emergency and outpatient settings.”
KPNC has established several programs in recent years to address the needs of patients with psychosis. In September 2020, KPNC initiated a pilot project in coordination with Aldea Children & Family Services to provide coordinated specialty care to KPNC members in the Napa-Solano service area with early psychosis. Aldea runs a pilot program called Supportive Outreach & Access to Resources (SOAR) to intervene in psychosis in its early stages; 70 patients have participated so far.
KPNC has also built an innovative program for patients with severe and persistent mental illness (SPMI) that connects them with specially trained clinical pharmacists who can support their medication use and help track symptoms through telehealth visits. Research has found the pharmacist support is beneficial and safe.
This study is part of a larger effort to use sophisticated data techniques to predict which patients might benefit from screening for psychosis risk. That research is led by study co-author Matthew Hirschtritt, MD, MPH, a psychiatrist and adjunct investigator with the Kaiser Permanente Division of Research. He previously discussed the project in a Research Radio podcast.
The study published in the American Journal of Managed Care was funded by the Kaiser Permanente Garfield Memorial Fund and the KPNC Office of Graduate Medical Education.
Additional co-authors were Christyn Haigler, MD, a former psychiatry resident at KPNC now in a fellowship at Georgetown University; and Andrea H. Kline-Simon, MS, with the Division of Research.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. KPDOR seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 720-plus staff, including 73 research and staff scientists, are working on nearly 630 epidemiological and health services research projects. For more information, visit divisionofresearch.kp.org or follow us @KPDOR.
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