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Arnold School of Public Health

Rural areas come out on top for quality of inpatient psychiatric care

November 23, 2022 | Erin Bluvas,

Amidst numerous headlines and reports that rural health care is unequal to urban in nearly every way, recent research from the Rural and Minority Health Research Center has revealed that the quality of inpatient psychiatric care is better in most rural settings. Published in Psychiatric Services, this new study found better follow-up care, better timely transmission of transition records to outpatient providers and lower rates of physical restraint use. However, they did find a sharper decrease in follow-up care performance in rural vs urban facilities.

“One in five adults experiences mental illness each year, and 25 percent of these individuals are diagnosed with serious mental illness – a number that has grown from 9.8 million in 2014 to 14.2 million just six years later in 2020,” says health services policy and management assistant professor Peiyin Hung, who is deputy director for the Center and lead investigator for the study. “Rural and urban residents are diagnosed with serious mental illness at similar rates, but rural areas are largely underserved due to health care facility closures and staffing shortages.”

Nearly 95 percent of rural counties lack an adequate mental health workforce. For example, in 2015, 65 percent of rural counties did not have a psychiatrist on staff, compared to 27 percent of urban counties. These staff shortages pose challenges for psychiatric units to achieve quality of care goals, including minimizing the use of restraints and isolation, careful planning and consideration for the use of multiple prescription medications, offering transition records at discharge and providing essential follow-up care – an important factor in preventing suicide attempts and deaths.

The present study examined data related to these metrics from 1,644 health care facilities between 2015 and 2019 to assess the quality of inpatient psychiatric services available to rural residents. Over three quarters of these hospitals (accounting for 1,254 facilities) were in urban areas, with 260 in large rural areas and 130 in small/isolated rural areas.

“The increases in mental illness in rural America and the persistent rural mental health access disparities require innovative ways to resolve, as rural psychiatric care facilities are not the same as urban facilities,” says Hung.

They found that rural hospitals were more likely to focus primarily on general medicine and surgery, whereas urban areas were more likely to have dedicated, specialized psychiatric hospitals. Despite this and other disadvantages (e.g., fewer beds; less likely to be accredited, offer alcohol/drug dependency services, be system affiliated), rural inpatient psychiatric care outperformed urban services on all quality of care measures except for the previously noted follow-up care performance trends.

“Patients hospitalized in psychiatric units often have complex conditions that require continual engagement with health care providers,” Hung says. “While the higher quality of inpatient psychiatric care in rural facilities is encouraging, it is important that we address the challenges related to follow-up care by supporting patients’ transition to communities through coordination with outpatient mental health providers. The rural population is more vulnerable to readmission, suicide death after discharge, emergency department visits for mental illness, and other adverse outcomes that can be mitigated by ensuring high quality continuity of care.”


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