Service Utilization in an HIV and LGBTQ Community Mental Health Clinic

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Service Utilization in an HIV and LGBTQ Community
Mental Health Clinic
NR7-72
Jacob Sacks, MD, Matthew Lezama, BS, George
Harrison, MD, Christina Mangurian, MD, James W.
Dilley, MD, Martha Shumway, PhD
University of California, San Francisco and San
Francisco General Hospital
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• Research Questions
• Who accesses services at a community mental
  health clinic targeting the underserved among the
  LGBTQ and HIV communities?
• Are there differences in demographics,
  psychiatric diagnoses, or major medical diagnoses
  between typical-utilizers and high-utilizers of
  clinic services?

Background While many authors have published on
the topic of high utilizers of mental health
services (1), there is a dearth of literature
describing the phenomena in the LBGTQ or
HIV-positive populations. The term high
utilizer has been used to describe a subset of
mental health consumers who consume a
disproportionate share of mental health services
and resources. Studies have found that between
5-18 of people consume 27-63 of the services
provided (2-6). Attempts have been made to
describe the demographic and clinical variables
associated with high utilization in the general
population.  In the general population, features
like homelessness, psychotic disorders, bipolar
disorder, and substance abuse diagnoses have been
shown to correlate with high service utilization
in large public mental health systems (7).  The
LGBTQ community is underserved by our healthcare
systems and underrepresented in our research.
LGBTQ individuals have higher rates of mental
health diagnoses and service utilization than
heterosexuals (8-12) in addition to high
incidence of substance use disorders (13, 14).
HIV-positive individuals also have high
prevalence of psychiatric diagnoses (15).
Previous findings indicate that nonwhites and
Hispanics in the HIV population may underutilize
outpatient services (16). Accurate
characterization of the subset of  LGBTQ and
HIV-positive consumers who are high utilizers
could have important implications for program
development. Since high utilization may indicate
unmet needs in this specific population,
describing the patterns of use and
characteristics of this group may help us to
allocate healthcare resources more efficiently
and effectively.

• Results Demographics

• Results Psychiatric Diagnoses
• Summary
• The percentage of clients with schizophrenia or
  any psychotic disorder was identical (16)
  between both groups.

Discussion The overall sample of individuals
accessing services at Alliance Health Project
suggests a population of mostly white,
gay-identified males with some college education
on SSI with stable housing, having high
prevalence of depressive disorders, anxiety
disorders, and substance use disorders. 79 are
HIV positive. It is difficult to say whether
high-utilization as defined in our study
represents over-utilization vs. increased
access to care in this typically underserved
population. Much of the published literature
defines high-utilization in inpatient and
emergency settings. It is possible that high
utilization of outpatient clinic services would
result in desirable decreases in the utilization
of emergency and inpatient services. More
research in this area would be useful. In our
study, identifying as gay or lesbian was
associated with higher likelihood of being a high
utilizer of services. This may be a result of the
targeted mission and welcoming environment of our
particular setting to this specific group.
Alternately, this may be reflective of the higher
rates of mental health diagnoses in lesbian and
gay populations.Latino and African American
individuals were less likely to be high utilizers
of clinic services. This could indicate that
individuals with higher service needs are more
likely to access services at agencies
specifically targeted to their specific
racial/ethnic group. The possibility of language
barriers is also considered. White individuals
were no more likely to be high utilizers.
Diagnosis of anxiety disorder other than PTSD
was associated with higher service utilization,
while diagnoses of psychotic and bipolar
disorders were not. Given that psychotic and
bipolar disorders are often associated with high
utilization in the literature, this may represent
a finding specific to our patient population or
clinical setting.  The substance use variables
indicate that having a substance-related disorder
diagnosed on axis I did not predict high service
utilization. However, having a substance use
disorder in remission was associated with higher
service utilization while current problem
substance abuse was not associated with high
service utilization. This may reflect the
difficulty that active substance users have
complying with outpatient treatment in a clinic
setting. It is also possible that those with
substance use disorders in remission are
utilizing more clinic services in order to
support their abstinence. Borderline personality
disorder was associated with high service
utilization whereas any personality disorder
was not. This may indicate an opportunity for
programming targeted to this specific group which
may increase the efficiency of service
allocation.HIV diagnosis was associated with a
lower likelihood of being a high utilizer of
services. This may indicate that a higher level
of engagement with primary care providers (which
is typical of the HIV positive population in out
clinic) may help address some of the mental
health needs in this population.  Of note,
diagnoses were assigned by a variety of
clinicians and not using a standardized
instrument, which may lead to individual and
cultural variability in reporting of certain
diagnoses (e.g., underdiagnosing of personality
or substance-use disorders due to stigma or
access to other services).Further efforts will
include increasing the sample size to better
examine the statistical significance of
relationships between client characteristics and
service utilization as well as further
characterizing the specific types of services
used (psychotherapy vs. group therapy vs.
medication management vs. case management vs.
substance abuse treatment) in relation to overall
service utilization.  
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• Results Medical Diagnoses
• Summary
• High users were less likely to have a medical
  diagnosis of HIV (72) compared to typical users
  (86).
• Combining both groups shows that 79 of all
  clients sampled had an HIV diagnosis.
• The percentage of clients with a diagnosis of
  diabetes was identically low in both groups (2).
• There was a statistically significant difference
  between the percentage of clients in with a lipid
  abnormality (ie hyperlipidema, dyslipidemia,
  hypercholesterolemia). 12 of high users were
  diagnosed with lipid abnormalities, compared to
  only 2 of typical users.

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• Methods
• Subjects Clients who used a high number of
  outpatient services (n50) and clients who used a
  typical number of services (n50) between March
  1, 2011 and February 28, 2012.
• Study Type Retrospective Chart Review
• Study Procedure
• High and typical service users were determined by
  analyzing all billing data during the study
  period. Clients were split into quintiles based
  on the number of service minutes they utilized.
  50 clients were randomly selected from the 3rd
  quintile (typical users) and 50 from the 5th
  quintile (high users).
• Using pre-existing intake assessments and
  progress notes, clients were characterized by
  their demographics, diagnoses, and social
  histories.
• Data Analysis
• Logistic regression was used to examine
  relationships between client characteristics and
  being a high user of outpatient services.

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Setting The University of California San
Francisco Alliance Health Project supports the
mental health of and wellness of the lesbian,
gay, bisexual, transgender, queer (LGBTQ), and
HIV-affected communities in constructing healthy
and meaningful lives. AHP, originally founded in
1984 as the AIDS Health Project, is one of the
oldest AIDS service organizations in the United
States. It serves more than 10,000 clients per
year, employs approximately 100 full- and
part-time employees, and has an annual budget of
about 6 million. AHP is a program of the
Department of Psychiatry of the University of
California San Francisco and is affiliated with
the Department of Psychiatry at San Francisco
General Hospital. In 2010, AHP expanded its
mission to provide services to the related but
distinct LGBTQ community. Using the clinical
structures which had been developed, services for
HIV negative individuals were expanded and
programs to meet the specific needs of the new
populations were designed.
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