Children's mental health system performance: Emergency department measures in TennCare

Background: Health care providers and policy makers have employed performance measurement strategies to improve the quality of health and mental health services. Examples include measures in the National Committee on Quality Assurance's HEDIS program. Little research has focused on process-based performance measures for mental health services or services for children beyond infancy. Yet, past research has documented an increase in ED utilization particularly for mental health problems, and these are an important source of crowding in EDs.

Methods: This analysis uses statewide TennCare Medicaid managed care data from 1997-2002 to calculate for children (4-17 y.o.): annual ED utilization rates; rates of admission to inpatient from the ED; and, rates of community follow-up care and re-admission to the ED. The analysis examines the effect of individual, provider, and community factors using hierarchical nonlinear (logistic) regression models.

Results: Rates of ED utilization among children receiving mental health services increased from 4% to 9%. Admissions to inpatient directly from the ED were stable over time (15% per year). Few children received subsequent specialty mental health treatment, while the proportion re-admitted to the ED increased from 9% to 16%. Provider effects accounted for most of the variation in the outcomes.

Conclusion: This study demonstrates the feasibility of simple utilization measures for mental health system performance monitoring; documents a growing reliance upon the ED for mental health care among children in Tennessee's Medicaid program, despite managed care; and, suggests variation in these measures depends more upon provider traits and locations than child factors.