Implementing the Quadruple Aim in Behavioral Health Care

Acute Service Use. This is defined as an admission to a medical or psychiatric emergency room or to a medical or psychiatric hospital or to a detoxification facility.

Brief review and suggested item(s). The CMS Adult Core Set includes “plan all cause readmissions” as a key quality metric.⁵⁵ Hospital readmissions are also endorsed by the National Committee on Quality Assurance as one of its Health Effectiveness Data and Information Set (HEDIS) measures and by the National Quality Forum. Readmissions, despite their widespread endorsement, are a somewhat controversial measure. Although readmissions are costly to the health care system,¹³⁶ the relationship between readmissions and quality is inconsistent. For example, Krumholz and colleagues¹³⁷ found differential rates of readmission for the same patient discharged from 2 different hospitals, which were categorized based on previous readmission rates, suggesting that hospitals do have different levels of performance even when treating the same patient. However, other data indicate that 30-day, all-cause, risk-standardized readmission rates are not associated with hospital 30-day, all-cause, risk-standardized mortality rates.¹³⁸

Chin and colleague found that readmissions to the hospital that occurred more than 7 days post-discharge were likely due to community- and household-related factors, rather than hospital-related quality factors.¹³⁹ Transitional care interventions that have successfully reduced 30-day readmission rates are most often multicomponent and focus not just on hospital-based interventions (eg, discharge planning, education) but on follow-up care in the community by formal supports (eg, in-home visits, telephone calls, outpatient clinic appointments, case management) and informal supports (eg, family and friends).^140-143 Further, qualitative evidence suggests that some individuals perceive psychiatric hospitalizations to be the result of insufficient resources or unsuccessful attempts to maintain their stability in the community.¹⁴⁴ Thus, unplanned or avoidable hospital readmissions may represent a failure of the continuum of care not only from the perspective of the health care system, but from the patient perspective as well.

Frequent or nonurgent use of EDs is conceptually similar to excessive or avoidable inpatient utilization in several ways. For example, overuse of EDs is costly, with some estimates suggesting that it is responsible for up to $38 billion in wasteful spending each year.¹⁴⁵ Individuals with frequent ED visits have a greater disease burden¹⁴⁶ and an increased risk of mortality compared to nonfrequent users.¹⁴⁷ Research suggests that individuals who visit the ED for non-urgent issues do so because of perceived difficulties associated with accessing primary care, and the convenience of EDs relative to primary care.^148-150 Moreover, similar to the hospital readmission literature discussed earlier, successful strategies to reduce high rates of ED utilization generally focus on continuum of care interventions, such as provision of case management services.^151-155

This evidence implies that frequent ED utilization and hospital readmissions may not be a fundamental issue of quality (or lack thereof) in hospitals or EDs but rather a lack of, or ineffectual, transitional and continuum of care strategies and services. To underscore this point, some authors have argued that a system that is excessively crisis-oriented hinders recovery because it is reactive rather than proactive, predicated on the notion that one’s condition must deteriorate to receive care.¹⁵⁶