Researchers have described trends indicating a shift in the locus of mental health treatment for older adults from inpatient to ambulatory care (1,2,3). Transfer of elderly patients from state hospitals to nursing homes as well as efforts to divert clients from state hospital care have been major causes of these trends. National and state policies aimed at increasing home- and community-based human services, along with the rising costs of care in inpatient and long-term nursing facilities, would predict the persistence of these trends. This report describes national survey findings about recent trends in the utilization of mental health organizations by older adults.
The analyses reported here are based on data from the 1994 biennial inventory of mental health organizations and general hospital mental health services conducted by the Center for Mental Health Services, part of the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. This complete enumeration of mental health organizations and general hospitals with separate psychiatric services is the most recent available national dataset that includes data on the mental health services provided to older adults. The analyses reported here also use data from three previous inventories to examine recent utilization trends.
All organizations included in the biennial inventory are requested to report the end-of-year number of clients in the facility's caseload who receive services in each of three settings: 24-hour hospital care, 24-hour residential care, and less-than-24-hour or ambulatory care. Data are reported by clients' age categories. Nonelderly adults, those age 18 to 64 years, are distinguished from older adults, those age 65 years and older. Since 1988 the survey form has requested data on each organization's older adult client census in two age categories, 65 to 74 years and 75 years and older.
Eighty percent of the 5,436 specialty mental health organizations operating in fiscal year 1994 provided services to persons who were age 65 or older. These organizations included 603 psychiatric hospitals, 1,394 general hospitals with separate psychiatric services, 157 Veterans Affairs medical centers, and 2,212 outpatient clinics.
At the end of fiscal year 1994, these organizations reported serving about 350,000 older adults. Most clients (93 percent) received less-than-24-hour care; the remainder received care in either a psychiatric hospital or a general hospital (6 percent) or in a 24-hour residential treatment facility (1 percent).
Previous analyses have shown that utilization rates for inpatient services decreased faster for all older adults than for nonelderly adults from 1986 to 1990 (2). More recent data from the biennial inventories show similar decreasing trends, as F1 illustrates. In addition, they show that the decreasing trend has been most dramatic among the oldest clients. Recent utilization rates of inpatient services by the oldest group have been lower than those for the two other adult age groups. Older adults aged 65 to 74 have also reduced their inpatient utilization substantially, again faster than nonelderly adults. Yet in 1994 their rate remained slightly higher than that of nonelderly adults.
Although utilization rates for ambulatory services among older adults have increased, these increases have not been as great as among nonelderly adults. Again, the greater change among older adults has been in the oldest client category. The rate for oldest clients increased by 173 per 100,000, while the rate for persons age 65 to 74 years increased by 152 per 100,000.
Data for both settings show steady inverse trends in the rates of utilization of inpatient and ambulatory services by all adults. Although the data confirm the continuation of inverse trends among all older adults (those age 65 years and older), they also indicate that these inverse changes are particularly evident among the older of the two elderly groups. Clients age 75 and older had a rate percentage decrease of about 37 percent in utilization of inpatient services and a similar rate percentage increase in utilization of ambulatory services from 1988 to 1994. Clients age 65 to 74 years had an inpatient rate percentage decrease of 30 percent and an ambulatory rate percentage increase of 14 percent.
Using age-specific rates to compare service utilization between age groups across years can mask substantial absolute changes in provision of services, especially services provided to persons age 75 years or older. In absolute terms, approximately 12,300 inpatients were members of this oldest group in 1988. By 1994 this number had decreased to nearly 8,800, a drop of 28 percent. Over the same period the numbers of oldest clients on the outpatient rolls increased by 59 percent, from 57,500 in 1988 to 91,600 in 1994.
As the absolute number of inpatient clients decreased and the number of ambulatory clients increased between 1988 and 1994, there was also a marked increase of 15.7 percent in the overall size of this oldest age group. Thus although substantial changes occurred in the absolute amounts of services provided, rates of utilization for the oldest age group changed more modestly during this time because of the population increase.
These findings have relevance to three policy issues: the substitution of ambulatory care for inpatient care, the amount of unmet service need, and the amount of resources needed for future services.
The inverse trends of inpatient and ambulatory rates among both older adult age groups suggest a substitution of service modalities. It is possible that some of the older adults who are on the ambulatory rolls in 1994 would likely have been inpatients in earlier years. These utilization rates could have been influenced by the combined impact of the shift from inpatient to nursing facility care in many states and the implementation after 1987 of Omnibus Budget Reconciliation Act regulations to enhance outpatient mental health service to the clients of nursing facilities. Still, these data only suggest that service substitution has occurred, because persons who might have received inpatient services in the past may not currently be receiving ambulatory services. Further examination of potential substitution of ambulatory for inpatient services among specific client cohorts is required.
Older adults have substantial unmet need roughly comparable to that of younger adults (4,5). The continuing low utilization rates for ambulatory services and the modest increases in rates of ambulatory care for older adults pose the question of whether mental health specialty organizations will be able to meet the needs of this group. Thus even as ambulatory capacity in specialty mental heath organizations increases, additional research is required to examine the extent to which service needs are met by the combination of specialty mental health organizations and health care providers working in other settings.
These findings indicate that planners will be challenged to maintain or to increase the rate of ambulatory service use by older persons. Although ambulatory service capacity for older adults has been expanding and likely will continue to expand, the approaching population explosion among older adults will parallel or exceed potential enhancement in capacity (6). Improving older adults' utilization rate for ambulatory services will surely require an outstanding effort, certainly as strong as the effort that has promoted the shifting locus of care from inpatient to ambulatory settings already reflected in these national biennial inventories.
This analysis was supported by the research infrastructure support program of the National Association of State Mental Health ProgramDirectors Research Institute under grant 5-R24-MH53148 from the National Institute of Mental Health. The author thanks Howard Goldman, M.D., Ph.D., and Michael Witkin, M.A., C.P.A., for their help with this project.
When this work was done, Dr. Demmler was a senior research fellow at the National Association of State Mental Health Program Directors Research Institute in Alexandria, Virginia. She currently is a sociologist with Heartland Network for Social Research in Denver. Address correspondence to her at 1214 Detroit Street, Denver, Colorado 80206. This paper is one of several in this issue on mental health services research conducted by new investigators.
Rates of utilization of inpatient and ambulatory mental health services by US. adults, 1988-1994, in number of clients per 100,000 civilian population1
1 Data sources: biennal inventories of mental health organizations and general hospital mental health services for 1988, 1990, 1992, and 1994 conducted by the Center of Mental Health Services of the Substance Abuse and Mental Health Services Administration