Patient Flow and Reutilization of Crisis Services Within 30 Days in a Comprehensive Crisis System

Pima County is the second most populous county in Arizona, with a population of 1.06 million, 546,574 of whom reside in the city of Tucson. Pima County shares a border with Mexico, and over one-third (38.5%) of county residents identify as Hispanic or Latino. Racial demographic characteristics are as follows: 84.2% White, 50.1% non-Hispanic White, 4.5% Black or African American, 4.4% American Indian or Alaska Native, 3.4% Asian, and 3.3% two or more races (12). The crisis system in Pima County is overseen by the RBHA, which contracts with multiple provider organizations to deliver services (13). The mobile crisis service system comprises 12–16 two-person teams staffed by a combination of clinicians and peers who are dispatched by the crisis line, are required to respond within 60 minutes, and provide 24/7 coverage. The CRC, located in Tucson, provides 24/7 access to crisis services to anyone in need, including individuals experiencing acute distress who are actively suicidal, violent, intoxicated, or under an involuntary commitment. Individuals arrive as walk-ins, are referred from mobile crisis services, are transported by law enforcement, or are transferred from EDs. To incentivize law enforcement to use the crisis center instead of a jail or the ED, police officers are never turned away and can return to patrol duties within 10 minutes. “Medical clearance” at an ED is not required before arrival. Individuals with low levels of distress are seen in the clinic-like urgent care area and typically discharged within 2 hours. Individuals with more complex needs receive treatment in the secure 23-hour observation unit, which is staffed by an interdisciplinary team of 24/7 onsite medical providers (psychiatrists, nurse practitioners, or physician assistants), registered nurses, case managers, behavioral health technicians, and peers. Individuals who are in need of additional treatment after the 23-hour observation period are admitted to the short-term inpatient unit or transferred to one of several external inpatient psychiatric facilities. A second crisis stabilization facility in Tucson provides 23-hour observation and inpatient services only to individuals who arrive voluntarily and focuses on populations with substance use disorder needs.

In this cross-sectional study, we utilized data from two sources: AHCCCS Medicaid claims and EHR data from Connections Health Solutions, which operates the CRC. The AHCCCS claims and encounter data used in this study were provided by the Arizona State University Center for Health Information and Research. The initial analysis of AHCCCS data between January 10, 2018, and January 3, 2020, included all claims with billing codes for mobile crisis services (CPT code H2011), crisis facilities (CPT code S9484 or S9485), EDs (Universal Billing [UB] codes 0450–0459 or 0981 with a diagnosis of mental disorder or substance use disorder as defined by the Clinical Classifications Software Refined [CCSR] categories 650–670, with the exception of intellectual and developmental disability diagnoses [653, 654, and 655]), and inpatient facilities (UB codes with bill types 11x and 12x or revenue code 0114 with a diagnosis of mental disorder or substance use disorder). Records for people identified as dually eligible for Medicaid and Medicare were excluded. The claims data were then merged with all available CRC EHR data from the same time frame on the basis of AHCCCS IDs and crisis episode dates for all adults ages 18–64.

AHCCCS claims were categorized as mobile crisis, crisis facility, ED, or inpatient on the basis of the related billing codes used for inclusion. AHCCCS covers mobile crisis and crisis facility services for anyone in need, regardless of Medicaid enrollment or eligibility (including people with private insurance that does not cover crisis services), for up to 72 hours (13), although approximately 80% of Arizonans seeking crisis services are Medicaid enrollees (14). If a claim for a higher level of care occurred within 72 hours of the initial claim, this subsequent claim was considered an escalation of care in the same crisis episode and was consolidated, with a defined starting point and end point (these data are available in the online supplement to this article). For example, an individual with a mobile crisis claim followed by a crisis facility claim within 72 hours would have “mobile crisis” as the starting point and “crisis facility” as the end point. A stand-alone crisis facility claim with no subsequent claims within 72 hours would have “crisis facility” as both the starting point and end point. These crisis care sequences were used as the basis for the flow analyses presented in Sankey charts and as independent variables in a generalized estimating equation (GEE) analysis.

Records of the CRC’s 24/7 urgent care and 23-hour observation unit were considered crisis facility records, in contrast to those of the CRC’s short-term inpatient unit, which was considered an inpatient facility. CRC records were consolidated into a single episode defined by the highest level of care if they met one of the following criteria: urgent care followed by observation, urgent care followed by observation followed by inpatient care, observation followed by inpatient care, and two or more episodes within 24 hours. A total of 41,026 crisis episodes were identified in the AHCCCS claims, of which 9,202 were matched with CRC records and consolidated, representing 5,530 unique individuals. Unmatched episodes represented either individuals who received no crisis facility services (e.g., mobile crisis or ED only) or individuals who received care at the other crisis facility or other inpatient units located in Pima County.

The crisis service reutilization outcome variable was defined as any new crisis service (mobile crisis, crisis facility, ED, or inpatient) with a start date within 30 days of the index crisis episode’s end date. The four crisis service categories were used for Sankey charts.

Demographic variables, including sex, age, and race-ethnicity, were created on the basis of AHCCCS claims data. Homelessness status was based on the most recent documentation in the EHR. A variable for rural versus urban residence was created with the AHCCCS claim record of a patient’s address and the U.S. Census Bureau’s 2010 urban-rural classification definitions. Insurance status was simplified into a dichotomous variable, indicating enrollment (yes or no) with AHCCCS Medicaid, on the basis of the claims data.

Diagnosis variables were created on the basis of AHCCCS claims and the CCSR categories. A single categorical variable was created for mental disorders when used as the primary diagnosis, including anxiety disorder, bipolar disorder, depressive disorder, and psychotic disorder, or no diagnosis. Dichotomous variables were created when the claim included any diagnosis (including nonprimary) for alcohol use disorder, opioid use disorders, stimulant use disorders, and suicidality (on the basis of ICD-10 Z codes and clinical documentation). Clinical records indicating blood or urine toxicology positive for alcohol or methamphetamine were also incorporated into these dichotomous variables. We created a dichotomous variable to indicate whether the index episode started with mobile crisis services. Finally, we used EHRs to create a variable describing an individual’s legal status during the crisis facility visit: voluntary throughout, involuntary throughout, converted from involuntary to voluntary, or converted from voluntary to involuntary.

To account for potential correlations between outcomes for individuals with multiple crisis episodes, we used GEE analysis to create an overarching model of how the independent variables relate to 30-day reutilization. We calculated adjusted odds ratios (AORs) for each independent variable, controlling for other independent variables, with a confidence interval of 95% and p<0.05 as compared with the reference variable. Episodes with an ED end point were removed from the model because of issues with model convergence. Statistical analyses were conducted by using SAS, version 9.4. A human subjects research review was conducted by the Arizona State University Institutional Review Board (protocol 00011824).

The flow analysis of AHCCCS claims included 41,026 crisis episodes (Figure 1A). Most episodes (N=23,547, 57.4%) began with mobile crisis or crisis facility services rather than ED or inpatient services. Of those episodes, 16,280 (69.1%) ended within the crisis system (mobile crisis or crisis facility). A total of 12,093 (29.5%) episodes ended at a crisis facility.

The analysis of 30-day reutilization for the subset of individuals who received crisis facility services at the CRC included 9,202 episodes (Figure 1B). Most CRC episodes (N=5,825, 63.3%) were not followed by 30-day reutilization. Of the 3,377 that were, most (N=2,466, 73.0%) occurred in a crisis setting—a specialized crisis facility (N=1,735, 51.4%) or mobile crisis unit (N=731, 21.6%)—rather than at the ED (N=462, 13.7%) or at an inpatient facility (N=449, 13.3%). Most of the episodes that began with an involuntary legal status ended with a voluntary status (N=1,700 of 2,865, 59.3%).

Demographic characteristics of the study population are shown in Table 1. AORs for demographic, clinical, and operational factors associated with 30-day reutilization are shown in Table 2 and discussed in the following text. (The working correlation matrix is included as a figure in the online supplement.)