Mental and Behavioral Health Diagnoses in Emergency Department and Inpatient Discharges by Healthy Places Index Ranking

In 2020, 24 percent of diagnoses in the emergency department and inpatient settings were mental health disorders, substance use disorders, or co-occurring disorders.

What is the Healthy Places Index?#

The Healthy Places Index (HPI) was developed by the Public Health Alliance of Southern California. The HPI maps data on 25 community characteristics such as access to healthcare, housing, and education into a single indexed HPI score. The healthier a community, the higher the HPI score. In the map below, each California ZIP code (where sufficient data was available) is scored and color coded to demonstrate its percentile ranking compared to other ZIP codes. To view and interact with a fully functioning version of the HPI map and data used in these HCAI analyses of behavioral health, visit https://map.healthyplacesindex.org/.

What is behavioral health?#

According to the American Medical Association, behavioral health is a term that generally refers to mental health (e.g., depression, anxiety disorders, schizophrenia, and other psychoses) and substance use disorders¹. It determines how we handle life stressors, crises, and stress-related symptoms. Behavioral health disorders are a concern for people of all ages. One in five adults have a clinically significant mental health or substance use disorder, and the prevalence and severity of mental health conditions among children and teens has increased.

How do the HPI and behavioral health relate to each other?#

According to the Office of Disease Prevention and Health Promotion, mental health is influenced by a person’s race, ethnicity, gender, age, income level, education level, sexual orientation, and geographic location ². Other social conditions, such as family and community dynamics, housing, employment, and school conditions also influence mental health risk and outcomes. A better understanding of how all these factors interact and impact communities plays an important role in improving and maintaining mental health.

According to the California Health Care Foundation, an average of 2.9 million Californians per year, age 12 and older (8.8 percent), had a substance use disorder in 2018-2019³.

In 2020, patients with behavioral health diagnoses accounted for 1,144,835 Inpatient (IP) hospitalizations and 2,090,085 Emergency Department (ED) treat and release visits, which is one third of all IP hospitalizations (3,444,532) and one fifth of all ED visits (10,023,851).

The visualizations present counts and percentages of diagnoses in three categories (mental health disorders, substance use disorders, and co-occurring disorders) for inpatient hospitalizations and emergency department visits in California hospitals. Counts and percentages can be compared across HPI rankings and filtered down to examine patient breakdown by expected payer, age group, race/ethnicity group, and sex. Total counts of diagnoses are displayed in bars on the left side of each visualization, while the percentage of total diagnoses represented by mental and behavioral health diagnoses are displayed on the right. The counts of mental and behavioral health diagnoses might be high relative to other HPI percentiles or patient categories, but encompass a relatively low percentage of diagnoses overall when factoring in diagnoses unrelated to mental and behavioral health, such as when looking at Medi-Cal patients in the least healthy HPI percentile. The reverse is true of Medi-Cal patients in the healthiest HPI percentile.  

HPI Map Key Findings#

• California’s lowest HPI scores are concentrated in the central valley and less densely populated areas.
• The highest HPI scores are concentrated among coastal urban areas and the High Sierra region.

Mental Health and Behavioral Health Diagnoses Key Findings#

• As HPI rankings move from least healthy to healthiest, counts of mental health and substance use disorders decrease, but diagnoses as a percentage of the overall total increase.
• All groups demonstrate higher percentages of mental health and substance use disorder diagnoses in the inpatient setting compared to the emergency department.
• The homeless patient population demonstrates significantly higher percentages of mental health and substance use disorder diagnoses compared to patients with an established residence at the time of service.

Mental Health and Behavioral Health Diagnoses by Patient Category Key Findings#

• When looking at patients’ expected payer, Medi-Cal patients present the highest percentages of mental health and substance use disorder diagnoses in the emergency department, and uninsured patients present the highest percentages in the inpatient setting.
• Patients aged 40-59 present the highest percentages of mental health and substance use disorder diagnoses compared to other age groups.
• Disparities in percentages appear when comparing race groups. American Indian/Alaska Native patients present the highest percentages of mental health and substance use disorder diagnoses in both settings, with Asian/Pacific Islanders presenting the lowest.
• Males present consistently higher percentages of mental health and substance use disorder diagnoses in both settings when compared to female patients.
• In all patient categories, the unhoused population presents much higher percentages of mental health and substance use disorder diagnoses when compared to the housed population.

How Payer Categories are Defined#

Medicare: Medicare Advantage, traditional Medicare; Medi-Cal: Medi-Cal managed care, fee-for-service Medi-Cal; Private Coverage: employer group coverage, individual coverage (including coverage purchased through Covered California), organized charity payers (e.g., March of Dimes, Shriners); Uninsured: uninsured patients, as well as instances when insurance does not cover the treatment, or the patient would like to keep the medical procedure private; Other Payer: Workers’ Compensation, County Indigent Programs, any third-party payment not included in any other category, stays for which no payment will be required by the facility (e.g. courtesy patients), and stays for which no valid expected payer was reported to HCAI.

How HCAI Created This Product#

• HCAI identified all occurrences of mental health, behavioral health, and substance use disorders in emergency department and inpatient hospitalizations in 2020. Definitions for behavioral health categories were adopted from the Massachusetts Center for Health Information and Analysis, which consulted with clinicians and the Agency for Healthcare Research and Quality. For more information, please visit: https://www.chiamass.gov/assets/docs/r/pubs/2021/CMSR-Emergency-Department-FY2019-Technical-Appendix.pdf.
• Clinical Classification Software Refined (CCSR) codes were used to define the categories: Mental Health Disorders (e.g., mood disorders; intentional self-harm, suicidal ideation, and suicide attempts; schizophrenia and other psychotic disorders), Substance Use Disorders (e.g., alcohol-related disorders; cannabis-related disorders, hallucinogens-related disorders), and Co-Occurring Disorders (at least one Mental Health Disorder and at least one Substance Use Disorder).
• The visualizations include behavioral health diagnoses as a primary or secondary diagnosis, but the percentages may still be under-represented due to undiagnosed behavioral health conditions.
• Patients were sorted into HPI percentiles based on ZIP code of residence at the time of service. Patients designated homeless by ICD-10 code beginning with Z59 and/or ZIP code of ZZZZZ were sorted into HPI percentiles based on ZIP code of the health care facility at the time of service.
• This product uses suppression of small numbers. Any count of diagnoses below 11 was changed to 11 in the underlying dataset for de-identification purposes.
• HPI score data, percentile rankings, and instructions for download are available at https://map.healthyplacesindex.org.

¹American Medical Association, What is behavioral health?

²Office of Disease Prevention and Health Promotion, Mental Health

³California Health Care Foundation, Substance Use in California, 2022: Prevalence and Treatment

Additional Information#

Topic: Healthcare Utilization
Source Link: Healthcare Utilization – Patient-Level Administrative Data
Citation: HCAI – Patient Discharge Data, Emergency Department Data, 2020, Public Health Alliance of Southern California: Healthy Places Index 3.0, Massachusetts Center for Health Information and Analysis, Agency for Healthcare Research and Quality, Office of Disease Prevention and Health Promotion, California Health Care Foundation
Temporal Coverage: 2020
Spatial/Geographic Coverage: Statewide
Frequency: Annual