Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans

Background Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. Objective To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. Design Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. Participants 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. Main Outcome and Measures The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. Key Results In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96–0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86–0.98) and more concentrated care (OR range: 1.04–1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80–0.90; OR range: 1.16–1.30). Conclusions Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.