RESULTS: AIM 3 - 6114.pdf

Aim 3: To assess the extent to which the performance of PCMHs on health services utilization and quality of care for patients with SMI in rural areas varies with mental health workforce shortages and experience with SMI.

5.A. Primary Care Visits

The results of the GEE models showed that for people with SMI in a rural PCMH, the partial effect of living in a county with a high unmet need for mental health providers (<39%) was associated with five fewer annual primary care visits as compared to the average person with SMI living in a county with a low unmet need for mental health providers (Table 5.1). This result was similar and only

significant for the people with major depression and people with bipolar disorder. People with schizophrenia living in a county with a high unmet need for mental health providers only had nearly three fewer annual primary care visits as compared to people with schizophrenia living in a county with a low unmet need for mental health providers.

For people with SMI in a rural PCMH the partial effect of seeing a primary care provider with high experience with SMI was associated with approximately four more annual primary care visits as compared with people with SMI seeing a primary care provider with low experience with SMI. These results were similar for people with major depression. People with bipolar disorder and people with schizophrenia seeing a primary care provider with high experience with SMI also had an annual increase of primary care visits, though these results were not significant.

The interaction effect of experience with SMI and mental health workforce shortage was not significant for primary care visits. However, the direction of the interaction effect shows that for people with SMI and all of the diagnoses examined in a rural PCMH seeing a primary care provider with high experience with SMI differs between living in a county with a high unmet need for mental health

providers and living in a county with a low unmet need of mental health providers by fewer primary care visits. Specifically, living in a county with a low unmet need for mental health providers had a higher marginal effect of seeing a primary care provider with high experience with SMI on average for primary care visits (Table 5.1).

The addition of information on the percentage of unmet need for mental health providers in a county and the interaction effect of experience with SMI and mental health workforce shortage to the GEE model did not impact the other covariates in the model and were nearly identical to the Aim 2 GEE results for annual primary care visits.

5.B. Specialty Mental Health Visits

Though not significant, the results of the GEE models showed that for people with SMI and each of the diagnoses examined in a rural PCMH, the partial effect of living in a county with a high unmet need of mental health providers was associated with fewer annual specialty mental health visits as compared to people with SMI living in a county with a low unmet need of mental health providers (Table 5.2). For people with SMI in a rural PCMH the partial effect of seeing a primary care provider with high experience with SMI was associated with approximately six more annual specialty mental health visits as compared with people with SMI seeing a primary care provider with low experience with SMI. People with bipolar disorder and people with schizophrenia seeing a primary care provider with high experience with SMI also had an annual increase of specialty mental health visits, though these results were not significant.

The interaction effect of experience with SMI and mental health workforce shortage was not significant. However, the direction of the interaction effect showed that for people with SMI and all of the diagnoses examined in a rural PCMH seeing a primary care provider with high experience with SMI differs between living in a county with a high unmet need for mental health providers and living in a

county with a low unmet need for mental health providers by fewer specialty mental health visits. Specifically, living in a county with a low unmet need for mental health providers had a higher marginal effect of seeing a primary care provider with high experience with SMI on average for specialty mental health visits (Table 5.2).

The addition of information on the percentage of unmet need in a county and the interaction effect of experience with SMI and mental health workforce shortage to the GEE model did not impact the other covariates in the model and were nearly identical to the Aim 2 GEE results for average annual specialty mental health visits.

5.C. Inpatient Hospitalizations

The results of the GEE models showed that for people with SMI and each of the diagnoses examined in a rural PCMH, the partial effect of living in a county with a high unmet need for mental health providers and the partial effect of seeing a primary care provider with high experience with SMI did not significantly affect the likelihood of having an inpatient hospitalization (Table 5.3) or the number of average annual inpatient hospitalization (Table 5.4).

The interaction effect of experience with SMI and mental health workforce shortage was also not significant for the likelihood of having an inpatient hospitalization (Table 5.3) or the number of inpatient hospitalizations (Table 5.4). However, the direction of the interaction effect showed that for people with SMI and all of the diagnoses examined in a rural PCMH seeing a primary care provider with high experience with SMI differs between living in a county with a high unmet need for mental health providers and living in a county with a low unmet need for mental health providers by a higher

likelihood of an inpatient hospitalization and number of inpatient hospitalizations. Specifically, living in a county with a low unmet need for mental health providers had a lower marginal effect of seeing a

primary care provider with high experience with SMI on average for the likelihood of an inpatient hospitalization and the number of average annual inpatient hospitalizations.

5.D. Emergency Department Visits

Though not significant, the results of the GEE models showed that for people with SMI and each of the diagnoses examined in a rural PCMH, the partial effect of living in a county with a high unmet need for mental health providers was associated with a higher likelihood of an emergency department visit in the month as compared to people with SMI and each of the diagnoses examined in a rural PCMH living in a county with a low unmet need for mental health providers (Table 5.5). However, for people with SMI and people with major depression in a rural PCMH, the partial effect of living in a county with a high unmet need for mental health providers was significantly associated with approximately 0.3 more annual emergency department visits as compared to people with SMI and people with major depression living in a county with a low unmet need mental health providers (Table 5.6).

For people with SMI and people with major depression in a rural PCMH, the partial effect of seeing a primary care provider with high experience with SMI was associated with a 1.2-1.5 percentage point increase in the likelihood of an emergency department visit in the month as compared with those who saw a primary care provider with low experience with SMI (Table 5.5). For people with SMI and people with major depression in a rural PCMH, the partial effect of seeing a primary care provider with high experience with SMI increased annual emergency department visits by approximately half a visit as compared with those who saw a primary care provider with low experience with SMI (Table 5.6).

The interaction effect of experience with SMI and mental health workforce shortage was not significant for the likelihood of having an emergency department visit (Table 5.5) or the number of emergency department visits (Table 5.6). However, the direction of the interaction effect showed that for people with SMI and all of the diagnoses examined in a rural PCMH seeing a primary care provider with high experience with SMI differs between living in a county with a high unmet need for mental health providers and living in a county with a low unmet need for mental health provider by a lower likelihood of an emergency department visit and the number of average annual emergency department visits.

5.E. Medication Adherence

The GEE results showed that for people with major depression in a rural PCMH, the partial effect of living in a county with a high unmet need for mental health providers was associated with a 3.6 percentage point lower adherence to medication as compared with people with major depression living in a county with a low unmet need for mental health providers (Table 5.7). The partial effect of seeing a primary care provider with high experience with SMI as compared with seeing a primary care provider with low experience with SMI was not significant for each of the SMI diagnoses examined.

The interaction effect of experience with SMI and mental health workforce shortage was not significant for medication adherence. However, the direction of the interaction effect showed that for all of the diagnoses examined in a rural PCMH seeing a primary care provider with high experience with SMI differs between living in a county with a high unmet need for mental health providers and living in a

county with a low unmet need of mental health provider by being more adherent to medications. Specifically, living in a county with a low unmet need for mental health providers had a higher marginal effect of seeing a primary care provider with high experience with SMI on average for medication adherence (Table 5.7).

5.F. Aim 3 Results Summary

The primary hypothesis for Aim 3 was that in the rural PCMH, people with SMI would have higher health services utilization and medication adherence when living in a county with lower unmet need for mental health providers and seeing primary care providers with high experience with SMI. More specifically, it was hypothesized that people with SMI living in a county with lower unmet need for mental health providers and seeing primary care providers with high experience with SMI would have more primary care visits, specialty mental health visits, and more adherent to medications, but fewer inpatient hospitalizations and emergency department visits than people with SMI seeing primary care providers with low experience with SMI. The interaction effect between unmet need for mental health providers and provider experience with SMI was not significant for any of the outcome measures. Therefore, the hypothesis for Aim 3 was not supported.

Despite the null findings, additional research on specialty mental health workforce shortages in rural PCMHs in other states may produce different results. In North Carolina, the measure for specialty mental health workforce shortages, percentage of unmet need for mental health providers had a large range (i.e. 5%-94% unmet need), but when the upper outlier of 94% unmet need is removed, the highest

value of unmet for mental health providers is 53%, much lower than might be found in rural areas of other states. Additional data from other states would likely provide more variability in the measure for unmet need of mental health providers as well as provide a larger sample of rural counties and of people with SMI could further inform the research presented here.

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