Hospital Management of Suicidal Older Adults and Subsequent Mortality in Medicare and Medicare Advantage Enrollees

Suicide rates increase with age and adults aged 65+ years are the fastest growing age group seeking emergency care in general hospitals for suicidal ideation. Most older adults who present for clinical evaluation of suicidal ideation or self-harm are admitted to inpatient care. However, suicide rates following hospitalization for suicidal thoughts or behaviors are up to 200 times the global suicide rate, with most deaths occurring within the first few months post-discharge. 

Despite growing research that type of Medicare enrollment (i.e., capitated Medicare Advantage vs. fee-for-service Medicare) is associated with significance differences in healthcare quality and mortality, very little geriatric mental health research has compared outcomes based on Medicare type. As roughly 1 in 3 older adults are enrolled in Medicare Advantage, research is urgently needed to identify potential differences in mental health care quality and key outcomes associated with Medicare coverage.

The goal of this Young Investigator award is to conduct the first national study examining treatment and mortality outcomes following hospital-based care for suicidal ideation or self-harm in the US geriatric population. This proposal builds upon current mixed methods research that uses fee-for-service Medicare claims merged with other national data to examine treatment outcomes in a geriatric sample of over 52,000 emergency department encounters for suicidal thoughts and behaviors. This proposal will supplement the existing database with three additional files: (1) Medicare Advantage claims, (2) Medicare Part D prescription claims, and (3) National Death index data. Our rigorous quantitative analysis will be enriched by input from diverse stakeholders to identify possible service delivery enhancements not readily identifiable in administrative data. The specific aims are: 

1)    To determine which type of Medicare coverage and patient, hospital, and regional factors influence the probability of inpatient admission in suicidal older adults and discharge destination (home vs. institutional care) among those who were hospitalized. 

2)    Among older adults discharged to home, to identify which type of Medicare coverage, patient, hospital, and regional factors are associated with timely outpatient mental health follow-up care, repeat encounters for suicidal thoughts or behaviors, and all-cause and suicide mortality.

3)    To help interpret the findings from Aims #1 and #2 through key informant interviews with diverse stakeholders to understand how to make best use of available services and create effective and timely linkage to community care following hospital-based care for suicide risk.

The primary objective is to assemble an R01 project using the current study as preliminary data to highlight the feasibility and significance of this topic. I will propose to link 10 years of claims and mortality data to identify proximal and longitudinal predictors of suicide death, supplemented by key informant interviews, to frame key targets for improved care practices and policies across the healthcare chain.

Preventing suicide is one of the great challenges facing the US healthcare system. This project will provide valuable information to healthcare planners about the delivery and financing of mental health services for the rapidly growing older adult Medicare population.