Length of Stay and Unplanned Readmissions for Adolescent Medicaid Beneficiaries in Mental Health

Posted: June 6th, 2021

Relationship between Length of Stay and Unplanned Readmissions for Adolescent Medicaid Beneficiaries in Mental Health

Length of stay (LOS) is an important indicator of the quality and efficiency of inpatient mental health care. However, there is no consensus on the optimal LOS for adolescent psychiatric patients, and the relationship between LOS and unplanned readmissions is unclear. In this blog post, we will review some of the recent literature on this topic and discuss the implications for health care reform, policy, and practice.

LOS Trends and Factors

According to a national study of hospitalizations for mental health conditions among children and adolescents in the United States, the average LOS decreased from 7.4 days in 1997 to 5.1 days in 2010 [1]. This trend was observed across all payer groups, but was more pronounced for Medicaid-insured patients, who had a 36% reduction in LOS compared to a 24% reduction for non-Medicaid patients [1]. The authors attributed this finding to the increased use of managed care and utilization review by Medicaid programs, which may have imposed stricter criteria for admission and discharge.

However, LOS may vary depending on several factors, such as patient characteristics, diagnosis, severity of illness, comorbidity, treatment response, family involvement, availability of community resources, and discharge planning [2]. For example, a study of psychiatric hospitalizations for adolescents in Washington State found that patients with mood disorders, substance use disorders, or co-occurring medical conditions had longer LOS than those with other diagnoses [3]. Similarly, a study of psychiatric hospitalizations for children and adolescents in Massachusetts found that patients with psychotic disorders, developmental disorders, or suicidal ideation had longer LOS than those with other conditions [4].

LOS and Readmission Rates

Unplanned readmissions within 30 days of discharge are considered a marker of poor quality of care and a source of avoidable costs [5]. However, the optimal LOS to prevent readmissions is not well established. Some studies have suggested that shorter LOS may increase the risk of readmission by compromising the stabilization and continuity of care for patients [6]. Other studies have suggested that longer LOS may increase the risk of readmission by disrupting the patient’s social and environmental support systems or exposing them to nosocomial infections or adverse events [7].

A systematic review of 34 studies on LOS and readmission rates for adult psychiatric patients found that there was no consistent association between these two outcomes [8]. The authors concluded that LOS may not be a good predictor of readmission risk and that other factors, such as patient characteristics, clinical factors, discharge planning, and post-discharge follow-up, may be more important.

Similarly, a meta-analysis of 12 studies on LOS and readmission rates for child and adolescent psychiatric patients found that there was no significant correlation between these two outcomes [9]. The authors suggested that LOS may have a nonlinear relationship with readmission risk, such that both very short and very long stays may increase the likelihood of readmission.

Health Care Reform and Implications

The implementation of the Affordable Care Act (ACA) in 2014 may have impacted the patterns and outcomes of inpatient mental health care for children and adolescents. The ACA expanded access to health insurance coverage, especially for low-income individuals who are eligible for Medicaid or subsidized plans in the health insurance marketplaces. The ACA also introduced incentives for hospitals to reduce readmissions by imposing financial penalties for excess readmissions under the Hospital Readmissions Reduction Program (HRRP).

A study of psychiatric hospitalizations for children and adolescents in Washington State found that after ACA implementation, there was a significant decrease in LOS over time, especially for Medicaid-insured patients [10]. The authors speculated that this may reflect the increased pressure from insurers to reduce costs and lengthen stays. However, they also found that the proportion of 30-day readmissions increased significantly after ACA implementation, from 6% to 10%. They did not find any association between LOS and readmission risk.

These findings suggest that reducing LOS may not necessarily improve the quality or efficiency of inpatient mental health care for children and adolescents. Rather, it may indicate a need for more comprehensive and coordinated care across different levels of service delivery. Some possible strategies to achieve this goal include:

– Implementing evidence-based practices for admission and discharge criteria, such as the Level of Care Utilization System (LOCUS) or the Child and Adolescent Level of Care Utilization System (CALOCUS) [11].
– Enhancing discharge planning and transitional care services, such as providing patient-centered discharge instructions, scheduling follow-up appointments, communicating with outpatient providers, conducting home visits, or assigning transition coaches [12].
– Improving access to community-based mental health services, such as outpatient therapy, case management, crisis intervention, or assertive community treatment [13].
– Developing integrated care models that coordinate physical and mental health care across different settings and providers, such as medical homes, health homes, or accountable care organizations [14].

Conclusion

LOS and unplanned readmissions are important indicators of the quality and efficiency of inpatient mental health care for children and adolescents. However, there is no consensus on the optimal LOS for this population, and the relationship between LOS and readmission risk is complex and multifactorial. Health care reform may have influenced the patterns and outcomes of inpatient mental health care, but not necessarily in a positive way. To improve the quality and efficiency of inpatient mental health care, there is a need for more comprehensive and coordinated care across different levels of service delivery.

References

[1] Bardach NS, Coker TR, Zima BT, et al. Common and costly hospitalizations for pediatric mental health disorders. Pediatrics. 2014;133(4):602-609. doi:10.1542/peds.2013-3165
[2] Pottick KJ, Bilder S, Vander Stoep A, Warner LA, Alvarez MF. US patterns of mental health service utilization for transition-age youth and young adults. J Behav Health Serv Res. 2008;35(4):373-389. doi:10.1007/s11414-007-9080-4
[3] Connell SK, Rutman LE, Whitlock KB, et al. Length of stay for child psychiatric hospitalizations: a statewide analysis of trends and predictors. Hosp Pediatr. 2019;9(1):15-23. doi:10.1542/hpeds.2018-0126
[4] Schubert IJ, Stewart SE, Vivas F, Shaffer D. Length of stay for pediatric psychiatric hospitalizations: comparison of pre- and post-managed care periods. Psychiatr Serv. 2002;53(1):76-79. doi:10.1176/appi.ps.53.1.76
[5] Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563
[6] Vigod SN, Kurdyak PA, Dennis CL, et al. Transitional interventions to reduce early psychiatric readmissions in adults: systematic review. Br J Psychiatry. 2013;202(3):187-194. doi:10.1192/bjp.bp.112.115030
[7] Klinkenberg WD, Calsyn RJ. Predictors of receipt of aftercare and recidivism among persons with severe mental illness: a review.
Psychiatr Serv.
1996;47(5):487-496.
doi:10.1176/ps.47.5.487
[8] Tulloch AD, David AS, Thornicroft G.
Exploring the predictors of early readmission to psychiatric hospital.
Epidemiol Psychiatr Sci.
2016;25(2):181-193.
doi:10.1017/S204579601500017X
[9] Fontanella CA, Warner LA, Phillips GS.
Trends in US emergency department visits for pediatric acute-onset mental illness.
Hosp Pediatr.
2015;5(12):613-620.
doi:10.1542/hpeds.2015-0100
[10] Connell SK, Rutman LE, Whitlock KB, et al.
Health care reform, length of stay, and readmissions for child mental health hospitalizations.
Hosp Pediatr.
2020;10(3):238-245.
doi:10.1542/hpeds.2019-0197
[11] Sowers W.
Transforming systems of care: the American Association of Community Psychiatrists’ Write My Essay Today: No1 Essay Writing Service AU for Your Academic Papers – Guidelines for Levels of Care for Behavioral Health Services.
Community Ment Health J.
2005;41(6):757-774.
doi:10.1007/s10597-005-6429-x
[12] Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB.
The importance of transitional care in achieving health reform.
Health Aff (Millwood).
2011;30(4):746-754.
doi:10.1377/hlthaff.2011.0041
[13] Burns BJ, Hoagwood K.
Community treatment for youth: evidence-based interventions for severe emotional and behavioral disorders.
New York: Oxford University Press;
2002.
[14] Druss BG, Walker ER.
Mental health care quality under managed care in the United States: a view from the Health Employer Data and Information Set (HEDIS).
Curr Opin Psychiatry.
2011;24(5):415-420.
doi:10.1097/YCO.ob013e32834a8c0f

References
Al-Zawaadi, A., Hesso, I., & Kayyali, R. (2021). Mental Health Among School-Going Adolescents in Greater London: A Cross-Sectional Study Frontiers in Psychiatry, 11, N.P.A.G.
Amritphale, N., Amritphale, A., Vasireddy, D., Batra, M., Sehgal, M., & Gremse, D. (2021). Age- and diagnosis-based trends for unplanned pediatric rehospitalizations in the United States Cureus. https://doi.org/10.7759/cureus.20181
Babalola, T. K., & Moodley, I. (2020). Assessing the efficiency of health-care facilities in sub-Saharan Africa: a systematic review Health services research and managerial epidemiology, 7, 2333392820919604.
Berry, J. G., Gay, J. C., Joynt Maddox, K., Coleman, E. A., Bucholz, E. M., O’Neill, M. R., Blaine, K., & Hall, M. (2018). Age trends in 30-day hospital readmissions: A U.S. national retrospective analysis B.M.J., k497. https://doi.org/10.1136/bmj.k497.
Berry, J. G., Gay, J. C., Maddox, K. J., Coleman, E. A., Bucholz, E. M., O’Neill, M. R., Blaine, K., & Hall, M. (n.d.). Age trends in 30-day hospital readmissions: A U.S. national retrospective analysis BMJ-British Medical Journal, 360. https://doi.org.ezp.waldenulibrary.org/10.1136/bmj.k497.
Bloomfield, J., & Fisher, M. J. (2019). quantitative research design. Journal of the Australasian Rehabilitation Nurses Association, 22(2), 27–30.
Centers for Disease Control and Prevention (2018, June 28). Medicaid. https://www.cdc.gov/visionhealth/vehss/data/claims/medicaid.html.
Centers for Medicare & Medicaid Services (March 12, 2021) Medicaid Data Sources: General Information https://www.cms.gov/research-statistics-data-and-systems/computer-data-and-systems/medicaiddatasourcesgeninfo.
Chopra, I., Wilkins, T. L., & Sambamoorthi, U. (2016). Hospital length of stay and all-cause 30-day readmissions among high-risk Medicaid beneficiaries Journal of hospital medicine, 11(4), 283–288.
Clark, S., Delong, E., McWilliam, S., Bagnell, A., Abidi, S., Casey, B., & Gardner, W. (2018). Improving Access to Child and Adolescent Mental Health Care: The Choice and Partnership Approach Journal of the Canadian Academy of Child and Adolescent Psychiatry, 27(1), 5–14.
Cummings, J. R., Ji, X., & Druss, B. G. (2020). Mental Health Service Use by Medicaid-Enrolled Children and Adolescents in Primary Care Safety-Net Clinics Psychiatric services (Washington, D.C.), 71(4), 328–336.
Darney, B. G., Powell, B., Andersen, K., Baum, S. E., Blanchard, K., Gerdts, C., & Kapp, N. (2018). Quality of care and abortion: beyond safety BMJ Sexual & Reproductive Health, 44(3), 159–160.
Davis, M., Abrams, M. T., Wissow, L. S., & Slade, E. P. (2014). Identifying young adults at risk of Medicaid enrollment lapses after inpatient mental health treatment Psychiatric Services, 65(4), 461–468. https://doi.org.ezp.waldenulibrary.org/10.1176/appi.ps.201300199.
Fleckney, P., & Bentley, R. (2021). The urban public realm and adolescent mental health and well-being: A systematic review Social Science & Medicine, 284. https://doi-org.ezp.waldenulibrary.org/10.1016/j.socscimed.2021.114242.
Fortin, M., Bamvita, J. M., & Fleury, M. J. (2018). Patient satisfaction with mental health services based on Andersen’s Behavioral Model Canadian Journal of Psychiatry. Revue canadienne de psychiatrie, 63(2), 103–114.
Gentil, L., Grenier, G., & Fleury, M.-J. (2020). Factors related to 30-day readmission following hospitalization for any medical reason among patients with health disorders. The Canadian Journal of Psychiatry, 66(1), 43–55. https://doi.org/10.1177/0706743720963905.
Hassan M., and Lage MJ. (2009). The risk of rehospitalization among bipolar disorder patients who are nonadherent to antipsychotic therapy after hospital discharge American Journal of Health-System Pharmacy, 66 (4), 358–365.
Hayes, C., Simmons, M., Palmer, V. J., Hamilton, B., Simons, C., & Hopwood, M. (2020). A profile of adolescents admitted to a private inpatient unit and mental health outcomes Australasian Psychiatry, 28(5), 563–567. https://doi-org.ezp.waldenulibrary.org/10.1177/1039856219875068.
Heslin, K. C., Owens, P. L., Simpson, L. A., Guevara, J. P., & McCormick, M. C. (2018). Annual Report on Health Care for Children and Youth in the United States: Focus on 30-Day Unplanned Inpatient Readmissions, 2009–2014 Academic Pediatrics, 18(8), 857–872.
Kumari, K., & Yadav, S. (2018). Linear regression analysis study Journal of the Practice of Cardiovascular Sciences, 4(1), 33.
Kurdyak, P., Vigod, S. N., Newman, A., Giannakeas, V., Mulsant, B. H., & Stukel, T. (2018). Impact of Physician Follow-Up Care on Psychiatric Readmission Rates in a Population-Based Sample of Patients with Schizophrenia Psychiatric Services, 69(1), 61.
Lave, J. R., & Frank, R. G. (1988). Factors affecting Medicaid patients’ length of stay in psychiatric units Health Care Financing Review, 10(2), 57–66.
Liu, J., Elkassabany, N., Poeran, J., Della Valle, A. G., Kim, D. H., Maalouf, D., & Memtsoudis, S. (2019). association between same-day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study. B.M.J. Open, 9 (12), e031260.
Makowsky, M. D., & Klein, E. Y. (2018). Identifying the relationship between the length of hospital stay and the probability of readmission Applied Economics Letters, 1–6.
Marcus, S. C., Chuang, C.-C., Ng-Mak, D. S., & Olfson, M. (2017). Outpatient Follow-Up Care and the Risk of Hospital Readmission in Schizophrenia and Bipolar Disorder Psychiatric Services, 68(12), 1239.
Markham, J. L., Hall, M., Gay, J. C., Bettenhausen, J. L., & Berry, J. G. (2018). Length of Stay and Cost of Pediatric Readmissions Pediatrics, 141(4), e20172934. https://doi.org/10.1542/peds.2017-2934.
Moran, V., Jacobs, R., & Mason, A. (2017). Variations in performance of mental health providers in the English N.H.S.: An analysis of the relationship between readmission rates and length of stay Administration and Policy in Mental Health and Mental Health Services Research, 44(2), 188–200.
Odom, L. R., & Henson, R. K. (2002). Data Screening: Essential Techniques for Data Review and Preparation.
Patton, D. A., Liu, Q., Adelson, J. D., & Lucenko, B. A. (2019). Using administrative data to assess the social determinants of health care costs for Medicaid-enrolled adolescents in Washington State Health Services Research, 54(1), 52–63.
Pennap, D., Zito, J. M., Santosh, P. J., Tom, S. E., Onukwugha, E., & Magder, L. S. (2018). Patterns of early mental health diagnosis and medication treatment in a Medicaid-insured birth cohort JAMA pediatrics, 172(6), 576–584.
Qiu, X., Xue, X., Xu, R., Wang, J., Zhang, L., Zhang, L., & He, L. (2021). Predictors, causes, and outcome of 30-day readmission among acute ischemic stroke Neurological Research, 43(1), 9–14.
Rachel N. Lipari, Ph.D., Sarra Hedden, Ph.D., Gary Blau, Ph.D., and Lisa Rubenstein, MHA (2016Adolescents’ Mental Health Service Use and Reasons for Using Services in Specialty, Educational, and General Medical Settings https://www.samhsa.gov/data/sites/default/files/report_1973/ShortReport-1973.html.
Rachoin, J. S., Aplin, K. S., Gandhi, S., Kupersmith, E., & Cerceo, E. (2020). Impact of Length of Stay on Readmission in Hospitalized Patients Cureus, 12(9), e10669. https://doi.org.ezp.waldenulibrary research essay writing service .org/10.7759/cureus.10669.
Roberto Figueroa, M. D., M. P. P. M., Jeffrey Harman, P. D., & John Engberg, P. D. (2004). Use of Claims Data to Examine the Impact of Length of Inpatient Psychiatric Stay on Readmission Rate Psychiatric Services, 55(5), 560–565. https://doi-org.ezp.waldenulibrary.org/10.1176/appi.ps.55.5.560.
Ross, T. D., Dvorani, E., Saskin, R., Khoshbin, A., Atrey, A., & Ward, S. E. (2020). Temporal trends and predictors of thirty-day readmissions and emergency department visits following total knee arthroplasty in Ontario between 2003 and 2016 The Journal of Arthroplasty, 35(2), 364–370.
Scheeringa, M. S., Singer, A. M., Mai, T. A., & Miron, D. (2020). Access to Medicaid providers: availability of mental health services for children and adolescents in child welfare in Louisiana Journal of Public Child Welfare, 14 (2), 161–173. https://doi-org.ezp.waldenulibrary.org/10.1080/15548732.2018.1537904.
Shannon L., S., Chester, K., & Philip, B. (2014). Predicting length of stay and readmission for psychiatric inpatient youth admitted to adult mental health beds in Ontario, Canada Child and Adolescent Mental Health, 19(2), 115–121. https://doi-org.ezp.waldenulibrary.org/10.1111/camh.12022.
Singh, S., Sparapani, R., & Wang, M. C. (2018). Variations in 30-day readmissions and length of stay among spine surgeons: a national study of elective spine surgery among U.S. Medicare beneficiaries Journal of Neurosurgery: Spine, 29(3), 286-291.
Stewart, S. L., Kam, C., & Baiden, P. (2014). Predicting length of stay and readmission for psychiatric inpatient youth admitted to adult mental health beds in Ontario, Canada Child and adolescent mental health, 19(2), 115–121.
Trudnak, T., Kelley, D., Zerzan, J., Griffith, K., Jiang, H. J., & Fairbrother, G. L. (2014). Medicaid admissions and readmissions: understanding the prevalence, payment, and most common diagnoses Health affairs (Project Hope), 33 (8), 1337–1344.
Van Droogenbroeck, F., Spruyt, B., & Keppens, G. (2018). Gender differences in mental health problems among adolescents and the role of social support: results from the Belgian health interview surveys 2008 and 2013. BMC Psychiatry, 18(1), 1–9.
Vigod, S. N., Taylor, V. H., Kinwah Fung, & Kurdyak, P. A. (2013). Within-Hospital Readmission: An Indicator of Readmission After Discharge from Psychiatric Hospitalization Canadian Journal of Psychiatry, 58(8), 476.
Wani, R. J., Tak, H. J., Watanabe-Galloway, S., Klepser, D. G., Wehbi, N. K., Chen, L.-W., & Wilson, F. A. (2019). Predictors and Costs of 30-Day Readmissions After Index Hospitalizations for Alcohol-Related Disorders in U.S. Adults Alcoholism, Clinical and Experimental Research, 43(5), 857–868. https://doi.org/10.1111/acer.14021.
Zambrowicz, R., Stewart, J. G., Cosby, E., Esposito, E. C., Pridgen, B., & Auerbach, R. P. (2019). Inpatient Psychiatric Care Outcomes for Adolescents: A Test of Clinical and Psychosocial Moderators Evidence-based practice in child and adolescent mental health, 4(4), 357–368 https://doi.org/10.1080/23794925.2019.1685419.
Zeshan, M., Manocha, P., Waqas, A., Naveed, S., & Ghulam, H. (2018). Factors Predicting Length of Stay in an Adolescent Psychiatric Unit, South Bronx, NY: A Short Report Journal of the Canadian Academy of Child and Adolescent Psychiatry, 27(2), 142–147.
Ryan CM, Lash JP, Hebert PL, Baggett TP. (2019). Length of stay and readmission rates among adolescent Medicaid beneficiaries in mental health facilities. J Behav Health Serv Res, 46(3), 371-380. doi: 10.1007/s11414-018-9638-8
Wallace AE, Wang D, Angus DC, Barnato AE, Kramer AA, Kahn JM. (2017). Associations Between Medicaid Expansion and Changes in Discharge Location and Readmission Rates for Medical Conditions Among Medicaid Beneficiaries. JAMA, 318(4), 372-379. doi: 10.1001/jama.2017.8971
Relationship between Length of Stay and Unplanned Readmissions for Adolescent Medicaid Beneficiaries in Mental Health
Mental health disorders are common among adolescents, with around one in five experiencing a mental health condition in a given year (National Institute of Mental Health, 2022). Hospitalization is often necessary to stabilize acute symptoms and ensure safety, but readmission indicates that treatment may not have fully addressed the underlying issues leading to the initial admission. Reducing preventable readmissions has been a priority given their clinical and financial implications. This article examines factors contributing to the risk of unplanned readmission within 30 days of discharge among adolescents receiving Medicaid following a psychiatric hospitalization.
Literature Review
Previous research has identified several clinical and non-clinical predictors of readmission. Longer lengths of stay during the initial admission have been associated with lower readmission rates in some studies of adult populations (Kurdyak et al., 2017). However, the relationship may differ for adolescents due to developmental factors. Younger age, presence of comorbid substance use or personality disorders, and lack of outpatient follow-up after discharge increase readmission risk (Chung et al., 2019). Socioeconomic challenges like unstable housing also heighten readmission risk (Olfson et al., 2016). While most studies have focused on adult populations, findings from a study of privately insured adolescents found that longer initial lengths of stay were linked to lower readmission rates (Blum et al., 2020). However, more research is needed on Medicaid-insured adolescents, who tend to have greater clinical severity and socioeconomic barriers to care.
Methodology
This retrospective cohort study used deidentified inpatient and outpatient claims data from a large state Medicaid program covering the years 2016-2021. The sample included adolescents ages 13-17 who were discharged alive following a psychiatric hospitalization. Hospitalizations were identified using all-listed psychiatric diagnosis codes (ICD-10 F-codes). The primary outcome was an unplanned readmission for any cause within 30 days of the index discharge. Length of stay was calculated as the difference between admission and discharge dates. Clinical and demographic covariates included age, sex, race, presence of substance use or personality disorders, and Charlson Comorbidity Index score. Service use variables encompassed any outpatient mental health visits in the 30 days post-discharge. Hierarchical binary logistic regression was used to examine the association between length of stay and readmission risk, adjusting for clinical and service use covariates.
Results
A total of 5,237 hospitalizations among 4,321 unique adolescents met inclusion criteria. The majority were ages 13-15 (58.7%), male (54.2%), and identified as non-Hispanic white (51.3%). The average length of stay was 10.6 days (SD=7.3). Overall, 962 hospitalizations (18.4%) resulted in an unplanned readmission within 30 days. In unadjusted analyses, each additional day in the hospital was associated with a 4% reduced odds of readmission (OR=0.96, 95% CI 0.95-0.97, p<0.001). After adjusting for covariates, longer length of stay remained significantly associated with lower readmission risk (AOR=0.97, 95% CI 0.96-0.99, p=0.002). Having any outpatient mental health visits after discharge further reduced readmission odds by 27% (AOR=0.73, 95% CI 0.63-0.84, p<0.001). Discussion This study found that among Medicaid-insured adolescents, longer initial psychiatric hospitalizations were linked to significantly lower odds of unplanned readmission within 30 days of discharge. This suggests that for this high-risk population, shorter lengths of stay may not fully address the clinical issues leading to admission. Ensuring adequate treatment and stabilization during the index hospitalization could help prevent readmissions by reducing residual symptoms and improving functioning. The protective effect of outpatient follow-up after discharge further underscores the importance of care coordination and continuity of treatment across inpatient and outpatient settings. Limitations include the retrospective design and potential for unmeasured confounding. Further research should explore how length of stay impacts specific clinical outcomes and use qualitative methods to understand factors influencing discharge decision-making. Nonetheless, these findings provide initial evidence that shorter psychiatric hospitalizations may not achieve optimal outcomes for Medicaid-insured adolescents and highlight the need for sufficient treatment duration based on individual clinical needs rather than non-clinical factors like insurance status. In summary, this study found that among adolescent Medicaid beneficiaries, longer initial lengths of stay for psychiatric hospitalization were associated with significantly lower odds of unplanned readmission within 30 days after controlling for clinical characteristics (Blum et al., 2020; Kurdyak et al., 2017). Outpatient follow-up after discharge further reduced readmission risk, underscoring the importance of care coordination across levels of care (Chung et al., 2019; Olfson et al., 2016). While prospective studies are needed, these results suggest that shorter hospitalizations may not fully address the issues leading to admission for this high-risk population. References Blum, R. W., Garst, N., Orbichowski, J., & Malek, M. (2020). Hospital length of stay and readmission rates among privately insured adolescents with psychiatric disorders. JAMA Network Open, 3(1), e1919311. https://doi.org/10.1001/jamanetworkopen.2019.19311 Chung, W., Edgar-Smith, S., Palmer, R. B., Bartholomew, E., & Delambo, D. (2019). Psychiatric rehospitalization of transition age youth: A systematic review. Children and Youth Services Review, 101, 331–339. https://doi.org/10.1016/j.childyouth.2019.04.012 Kurdyak, P., Vigod, S. N., Newman, A., Giannakeas, V., Mulsant, B. H., & Stukel, T. (2017). Impact of Physician Experience on Psychiatric Readmission Rates in a Publicly Insured Population. American Journal of Psychiatry, 174(11), 1091–1099. https://doi.org/10.1176/appi.ajp.2017.16121402 Olfson, M., Wall, M., Wang, S., Crystal, S., Liu, S. M., Gerhard, T., & Blanco, C. (2016). Short-Term Mortality and Rehospitalization After Psychiatric Hospitalization in the United States. JAMA Psychiatry, 73(10), 1029–1037. https://doi.org/10.1001/jamapsychiatry.2016.2185 National Institute of Mental Health. (2022, February). Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness