Older patients with serious mental illness: sensitivity to distance barriers for outpatient care.

OBJECTIVES: To inform health services delivery and to demonstrate the appropriateness of understanding access at the individual's level, we evaluated how patient characteristics affect sensitivity to access barriers. We examined one dimension of access: geographic accessibility. We assessed age differences in sensitivity to distance barriers for outpatient psychiatric and nonpsychiatric care among active Department of Veterans Affairs (VA) patients with serious mental illness.
METHODS: Among 142,055 VA patients with bipolar disorder, schizophrenia, or other psychoses in fiscal year 2000, separate random intercepts mixed models were estimated (cluster: nearest site) for outpatient psychiatric and nonpsychiatric visit day volume. In addition to distance and age group (<45, 45-65, or >65), covariates included gender, ethnicity, rural location, psychiatric diagnosis type, Charlson comorbidity level, initial treatment location, and psychiatric diagnosis X distance interactions. Differential distance effects by age were assessed using age X distance interaction terms.
RESULTS: Among VA patients with serious mental illness, distance limits the volume of VA outpatient visits. For nonpsychiatric outpatient care, patients older than 65 were substantially more sensitive to distance barriers (P < 0.0001). For psychiatric outpatient care volume, patients aged 45-65 had slightly increased sensitivity; however, this difference did not have clinical significance. DISCUSSION: The impact of geographic accessibility barriers depended on personal characteristics of the individual and the outpatient service type. For nonpsychiatric outpatient care, older VA patients were most negatively affected by distance barriers. Results may inform efforts to reduce barriers to health care among patients with serious mental illness.