When a patient with a mental health condition or a substance-use disorder seeks help in a hospital’s emergency department, the ER staff’s aim is to stabilize the patient for timely, comprehensive follow-up care by a primary-care clinician.
Study findings published April 14 in JAMA Network Open show that such handoffs rarely happen. In a review of Medicaid claims in Washington state, only 11% to 14% of behavioral health–related emergency department visits were followed by primary-care visits coded for the same diagnosis within 30 days.
“We suspected that primary-care follow-up may be infrequent, but we were surprised just how low the primary-care follow-up rates were,” said first author Dr. Jonathan Staloff, a family medicine physician and acting assistant professor of family medicine at the University of Washington School of Medicine.
The National Institute of Mental Health estimates that half of individuals with behavioral health conditions are untreated. To address that deficit, Washington state implemented a managed-care initiative in 2020 to improve behavioral health access and increase its integration with primary care.
Staloff and colleagues tracked 860,000 claims by 367,245 Medicaid patients in 2022 to see if the initiative was improving access. The claims showed that patients with mental health conditions and substance-use disorders (including alcohol) frequently visit emergency departments, which serve as safety nets when other community care is not readily accessible.
The reasons for lack of follow-up care are complex, according to Staloff.
“Handoff protocols may be limited for people with behavioral conditions. Such handoffs might not include primary care. Patients may not follow through due to the nature of their disease or its associated stigma, or primary-care capacity is restricted,” he said.
An accompanying editorial pointed out that low rates of primary-care follow-up should not necessarily be interpreted as an absence of care. Patients may instead seek specialty behavioral healthcare in inpatient or outpatient settings, residential treatment, peer recovery services or community-based care. These services are not consistently reimbursed by Medicaid and thus not observable in claims.
The study also found primary-care follow-up rates were markedly lower among non-Hispanic Black individuals and people experiencing homelessness. The rates likely reflect structural barriers and underscore the need for targeted investments to mitigate these obstacles.
“We know that race and other socioeconomic factors such as housing are key drivers of healthcare and health itself,” said Staloff. “Individuals with behavioral health conditions are also often stigmatized. So the intersection of race, housing insecurity, and living with a behavioral health condition can severely disadvantage people from receiving the care they need and deserve.”
The researchers found that patients with other chronic conditions, such as dementia, congestive heart failure, and lung disease, were more likely to receive primary-care follow-up after their emergency department visits. The authors surmised that this might reflect their established relationships with primary-care clinicians.
Staloff said the Washington Health Care Authority, the state agency that manages Medicaid, has tried to increase follow-up in these cases by including specific quality measures in their managed-care contracts with healthcare systems.
“This may encourage health systems to make this a specific area of focus for improvement,” he said.
The Washington Health Care Authority funded this work.
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