Community treatment of substance dependence in Bexar County: A case study of unmet need

Purpose:  The San Antonio population of nearly 1.4 million people is centered in Bexar County. The county hospital district (a.k.a, University Health System (UHS)) provides one county hospital. The MH/MR authority and provider of mental health services for Bexar county is the Center for Health Care Services (CHCS) which focuses on priority mental health populations rather than on substance abuse treatment; though substance abuse is a common co-morbidity. Throughout San Antonio, there are several private non-profit organizations that provide substance abuse care through grants and also contracts with the Texas Department of State Health Services (DSHS). The largest provider of substance abuse services is a charity known as the Patrician Movement (PM) which is the primary referral source for CHCS and UHS patients with substance dependence. This study assessed the clinical activity of these three primary organizations throughout the year 2006 to examine issues of the continuity of care our in community. Methods:  We gathered data on the numbers of substance-related UHS hospital admissions and the residential and outpatient treatment episodes available through CHCS and the PM. After counting the numbers of patients and numbers of episodes of care broken down by substance type, we identified types of services not generally available and estimated the costs of services provided. Results:  For the calendar year 2006, a total of 4,324 unique individuals arrived at UHS-Hospital for 5,456 episodes of care. 46.7% of those episodes were emergency room or observation only visits where patients were not admitted into the hospital because of the lack of need for “medical detoxification”. Patients who were admitted, spent a total of 18,155 bed days in the hospital. For 47% of all patient-episodes, and 52.7% of all admissions, alcohol was the primary diagnostic code. Of the 2,014 patients arriving at the hospital for an alcohol visit, 289 (14%) had more than one visit and accounted for 33% of the total episodes of care. The estimated costs to the hospital of all drug-related visits in 2006 was nearly 18 million of which more than 9 million was due to alcohol and 3 million was related to the 289 patients with more than one hospital visit. Under DSHS contract, the PM provided 1,609 patients with residential program beds for “psychosocial detox,” 52% of which were for opiate and only 25% of which were for alcohol. These numbers of inpatient/residential bed-day programs starkly contrast with all community outpatient program slots provided through CHCS and the PM which totaled only 2,564 during the year 2006. Conclusions:  In Bexar County, the hospital district expends a lot of money on inpatient detoxification and DSHS spends a significant portion of its annual allotment on inpatient and residential bed-day patient admissions. However, ample evidence shows that inpatient/residential programs without outpatient follow-up generally is insufficient. In our community, there are more patients consuming bed-day resources than we have available for outpatient treatment. We propose that shifting some portion of inpatient-residential $-resources towards outpatient care, will reduce the number of inpatient admissions and recidivism through the hospital district.