My physician neighbor works in several urban emergency departments where mental illness and substance abuse cases run rampant. When I ask him about the impact on readmissions, he lights up: “Are you kidding? It’s off the charts!”
He tells me of a man who shows up at one inner-city ER so often the stitches in previous head wounds have yet to heal. “And there’s this hideous trend to self-medicate these disorders with methamphetamines, as if opioids and alcohol weren’t bad enough.” He shakes his head.
You can’t capture the whole story of hospital readmissions without a close look at two mega comorbidities—mental illness and substance abuse. They inevitably exacerbate treatment for any other chronic disease or injury. While 77.3 percent of eligible U.S. hospitals are penalized for readmissions in a year, penalties for hospitals with dedicated psychiatric services are notably higher at 82.4 percent. The top admissions leading to readmissions are not acute myocardial infarction or pneumonia, as you might expect, but rather schizophrenia, bi-polar disorders and major depression. In Florida, for example, 27.4 percent of potentially preventable readmissions are related to these comorbidities. A study in Rhode Island showed the risk of readmission doubles when mental health or substance abuse comorbidities are present.
This is not a new problem. Twenty years ago, I worked as a volunteer in one of the same emergency departments where my physician friend works. Mental illness and substance abuse were driving up readmissions back then as well. One patient stands out in my mind. A lanky, unkempt man in his late thirties showed up one night with several bleeding head wounds needing stitches and swelling bruises on his lips and cheeks. “I just fell down the stairs,” he claimed, though it looked like a beating to me. Everyone on the ER staff seemed to know the man’s history of schizophrenia combined with alcohol and drug abuse, which led to a long series of accidents and fights—including a few tumbles down the stairs. They rolled their eyes not so much in judgment as helplessness. This was far from his first ER visit or inpatient stay at their hospital. And it would not be his last.
After getting the man x-rayed and stitched up, and ruling out a major concussion, several hours went by, then most of my shift, and still the ER staff couldn’t find anyone to take him home. He didn’t seem to know another soul. The man was out of danger and the ER staff needed space for other patients. They didn’t think his condition justified a hospital stay. So, the volunteer on shift, being me, got volunteered to take the man home. I loaded him into my rusty Honda Accord, holding the door open for him like he was my prom date, then buckling his seat belt while he sat passive and mute. We stopped at three different apartment buildings before we found his real one. He was so disoriented, likely still high, but also desperate to get home. He spoke only in staccato bursts: “Stop here,” “Turn left,” “No. This ain’t it.” He fidgeted and tapped his feet, opening and closing the car window at random. When we finally arrived at his actual apartment, he asked me to wait by the door until he turned on his TV. He walked across the dark room, turned on the TV set and collapsed into a chair in front of it. He didn’t turn on any other lights. He didn’t say goodbye, just waved me out. I could imagine him sitting there for hours, perhaps never going to his bed to sleep that night, even after his five-hour ER ordeal. I couldn’t picture him preparing a meal, putting on clean clothes or doing anything at all to take care of himself.
This experience captured for me the acute impact of mental illness and substance abuse on just about any other health condition or accident. A man like this has exhausted the patience and resources of friends and even immediate family. He’s perilously isolated. Without support, he’ll forget to take his prescribed medicine for schizophrenia; he won’t stay hydrated; he won’t eat until ravenous or sleep until exhausted.
Sure enough, the man showed up in the ER a few weeks later with fresh bruises and what looked like knife slashes on his face. He looked even more emaciated and drawn than before. They put him in a room near the nursing station, presumably to keep an eye on him. Yet amidst the turmoil of other trauma cases, he waited for hours. He paced the room holding a bloody towel to his face, talking out loud to an invisible adversary, finally dropping the towel on the floor so he could gesture more freely with his hands. He never tried to get out of the room. His wounds dried up to dark, purplish slashes before they stitched him up. At one point I asked the head nurse about how long he’d have to wait. She was annoyed. “We’ll get to him when we get to him. He’s fine.”
Now, clearly this man was being treated for new injuries that required treatment. This was not technically a “readmission,” but think for a moment about similar, ongoing scenarios, tens of thousands of them, playing out in our emergency departments and acute-care hospitals. Diabetic patients with mental illness forget to take their insulin or follow dietary restrictions; patients with major depression self-medicate with alcohol or opioids instead of—or in combination with—their antidepressants and miss therapy sessions they urgently need; stroke and cardiac patients with severe mental illness or drug addictions don’t manage the complex regimen of medications required to stabilize their chronic conditions. And on it goes. We’re talking about a healthy portion of the patients returning to our hospitals again and again—readmissions that could be prevented under better circumstances.
The last time I saw this man he arrived by ambulance with a severe abdominal wound. It appeared his toxic combination of mental ailments and substance abuse had once again led to a violent encounter or self-inflicted injury. He was likely off his medication again. The paramedics wheeled him right into the operatory where I was cleaning. I was trapped in the room during the worst of the crisis and got an eyeful. The man was eerily passive, staring blankly at the ceiling. Clutching his wound, blood welled up between his fingers. I was convinced he would die. The ER staff took decisive action, confident about the outcome, and the danger passed. Later in my shift, I asked about him. “Will he be okay?” “Him?” one doctor told me, “Oh, yeah. He’s indestructible.”
I know I’m painting a bleak picture here. What can really be done in such scenarios? Is Medicare’s Hospital Readmissions Reduction Program (HRRP) working? What about state Medicaid programs that target potentially preventable readmissions? Well, there is a growing body of evidence that these efforts are getting results. Many hospitals across the country are setting up sustained programs that reduce readmissions substantially. Nationwide, Medicare has measured a reduction of 29,000 readmissions over five years. Coordinated efforts in various states are paying off. In New York, for example, the ten largest hospitals decreased potentially preventable readmissions by 20 percent even when taking on more at-risk readmissions. Minnesota hospitals have collaborated to reduce readmissions by 19 percent. At the same time, innovative initiatives have been launched that address social factors as a way to improve patient outcomes. Listen to our podcast interview with the founders of the Patient Care Intervention Center in Houston about their efforts to decrease ER visits in vulnerable patient populations.
Though the impact of mental illness and substance abuse on readmissions is not a problem that’s going away, the coordinated effort and innovation developing across the country is making a difference.