The neighborhood environment to which your patient returns after
hospitalization can affect continuity of care.
That was the finding from a study of neighborhood environmental factors
affecting the likelihood that dually diagnosed patients returning home from a
hospitalization would attend their first outpatient follow-up visit and the
likelihood of rehospitalization. The study appeared online October 1 in
AJP in Advance.
For instance, researchers found that patients returning to a neighborhood
with a high vacant-housing rate and a greater distance from the nearest
Alcoholics Anonymous (AA) meeting location were more likely to skip their
first outpatient follow-up visit. Patients living in a neighborhood with a
greater number of Narcotics Anonymous (NA) meetings—possibly suggesting
a greater density of drug-addicted individuals in the nearby
environment—were more likely to be rehospitalized, while patients living
in areas with higher educational attainment were less likely to be
But lead author Gerald Stahler, Ph.D., of the Department of Geography and
Urban Studies at Temple University in Philadelphia, said that more important
than the specific variables that were found is the recognition of the
neighborhood environment as a factor in continuity of care.
"We need to expand our current assessment of the patient to include,
or at least consider, the role of the neighborhood environment in determining
follow-up care postdischarge," Stahler told Psychiatric News."
Currently, hospital discharge planning treatment staff rarely take into
account the overall quality of a patient's neighborhood or proximity to
certain environmental features that might trigger relapse and
rehospitalization. Patients are often influenced by the environment in which
they live, and therefore we believe that a more explicit focus on an
individual's neighborhood and community context represents an important but
understudied area in psychiatry. We believe that such a focus can potentially
enhance long-term care and treatment planning for psychiatric
The study coauthors were David Baron, D.O., of the Department of Psychiatry
and Behavioral Science at Temple; Jeremy Mennis, Ph.D., an associate professor
of geography and urban studies at Temple; and Rachel Cotlar, a research
assistant in the Department of Geography and Urban Studies.
The study was a retrospective analysis that utilized data extracted from
the medical charts of patients who had co-occurring substance use and mental
disorders and were treated in an acute inpatient unit at Temple University
Hospital—Episcopal Campus. Researchers obtained administrative data on
whether they arrived at their first outpatient appointment within a month of
discharge and whether they were rehospitalized within a year.
Also, Stahler said he and Mennis—who is an international expert in
geographic information science—have been developing a geographic
database relating to Philadelphia from a variety of publicly available data
sources. "We not only have census data, but also data that we believe
may relate to substance abuse, such as the locations of various kinds of
alcohol outlets, check-cashing stores, pawn shops, AA and NA meeting
locations, substance abuse treatment centers, and drug-arrest data," he
"Our predictor variables included individual-level data from the
medical charts, such as demographic information, psychiatric assessment
information, drug-use data, housing status, criminal justice history,
victimization data, and disability status," Stahler said. "The
selection of these variables was based on prior research relating to treatment
outcomes for the study population and information routinely available from
The study sample included 380 patients who, upon hospital admission, had
one or more mental health disorders and a positive urine drug screen for
prototypical illicit drugs. In general, the sample represented a primarily
poor, inner-city, minority population, with the majority being active cocaine
users (61 percent).
Slightly less than one-half of the patients in the sample (43 percent) kept
their initial outpatient appointment within 30 days of discharge from the
acute inpatient unit, and about one-half (51 percent) were rehospitalized
within one year.
"One of the biggest challenges in treating dually diagnosed patients
is maintaining aftercare treatment once they leave an acute inpatient
unit," Stahler said. "We know that substance abuse is a chronic
relapsing disease, and those with cooccurring mental disorders are at
particular risk for relapse and rehospitalization. So having patients continue
in treatment after leaving the hospital is particularly important.
Unfortunately, I don't believe that the number of patients in our study who
did not keep their outpatient appointments or who were rehospitalized within a
year were atypical for this kind of patient population. I think what this
speaks to is the necessity for finding ways to increase our ability to have
patients continue in treatment after hospitalization."
In addition to the vacant housing rate in a neighborhood and paucity of AA
meeting locations, other nonenvironmental factors predicting likelihood of
missing an outpatient follow-up visit were having the chief complaint of
bizarre behavior—that is, grossly inappropriate behavior—and
having a urine drug screen positive for heroin.
The likelihood of being rehospitalized within one year was greater for
Hispanic patients, patients who had at least one prior hospital admission, and
patients who lived in close proximity to an NA meeting location.
Stahler said that this kind of research—utilizing geographic
information systems and spatial modeling to look at the influence of the
neighborhood environment on continuity of care and rehospitalization for
dually diagnosed patients—is relatively new.
"If we better understand the elements of the neighborhood environment
that are likely to affect relapse, rehospitalization, and continuity of care
for patients, we can enhance our ability to provide better aftercare planning,
which will hopefully lead to more successful long-term patient
outcomes," he said.
"The Influence of Neighborhood Environment on Treatment
Continuity and Rehospitalization in Dually Diagnosed Patients Discharged From
Acute Inpatient Care" is posted at<http://ajp.psychiatryonline.org/cgi/reprint/appi.ajp.2009.08111667v1>.▪