High-Utilizer Psychiatry Patients: Understanding Repeated Crisis Care Needs
When someone in a mental health crisis arrives at the emergency room, it is often not the first time they have needed help. For a small group of people, mental health emergencies like this aren’t isolated events; they happen regularly, and the system keeps cycling them through without solving the underlying issue. It isn’t a simple problem, and in most cases, there is no simple cause or solution.
The first step in reducing psychiatric hospital readmissions is to identify who uses these services the most, why the cycle is so persistent, and what research shows about breaking that cycle. This article will explore:
- Who high utilizers of mental health care are.
- What causes repeated mental health crisis admissions.
- How revolving door mental health treatment develops.
- What effective crisis stabilization for mental health in adults requires.
- How to find complex psychiatric care management.
Who Are High Utilizers of Mental Health Care?
Frequent psychiatric hospitalizations have risen dramatically over the last thirty years. This increase is attributed to three primary factors:[1]
- Deinstitutionalization.
- Limited outpatient mental health resources.
- Rising substance use.
However, a large portion of the increased volume of mental health ER visits is accounted for by a small group: about four to five percent of patients generate up to 30 percent of all psychiatric emergency visits.[1][2] These patients are known as high utilizers. Mental health ER frequent visits from this population place a significant strain on often already overburdened systems.
Most research defines high utilizers in mental health care as patients with three to six emergency psychiatric visits per year.[2][3] Though most high utilizers are adults, adolescents are becoming a larger portion of this population. From 2011 to 2020, the number of emergency visits for adolescents increased from 4.8 million to 7.5 million.[4]
Acute vs Chronic High Utilizers
Regardless of age, high utilizers typically fall into one of two categories: acute or chronic. Acute high utilizers are often:[1]
- Unemployed.
- Unhoused or in an unstable housing situation.
- Don’t have an existing mental healthcare plan.
- Visiting the emergency room four or more times in a single quarter.
- Experiencing their first mental health episode, so they haven’t yet been connected to ongoing care.
Chronic high utilizers typically have:[1][5]
- Seven or more visits over a multi-year period.
- Mental healthcare in place.
- A history of multiple psychiatric hospitalizations and possibly incarcerations.
- Symptoms that have not responded well to treatment despite the patient being in the healthcare system for some time.
- A higher likelihood of having a personality disorder, psychotic disorder, or a co-occurring substance use disorder.
- A higher likelihood of returning to the hospital after being discharged.
Some key factors appear consistently among acute and chronic utilizers:[1][5][6]
- Low educational attainment.
- Limited social support, no caregiver, little or no family involvement, or being unmarried.
- Diagnosed with a psychotic disorder, especially schizophrenia.
- Prior psychiatric hospitalizations.
Given how complex their situations tend to be, high utilizers usually have longer and more expensive treatment stays than average emergency psychiatric situations. The top five percent of high utilizers account for up to 50 percent of total healthcare costs.[7]
Furthermore, frequent psychiatric admissions can contribute to:[1][3]
- Overcrowding.
- Staff burnout.
- Increased wait times for other patients.
- A general decrease in the quality of care for all patients.
These repeat visits typically reflect issues with the system, like:[1][3]
- Inadequate outpatient support.
- Insufficient community support.
- Poor discharge planning.
Why Do Some Patients Keep Coming Back?
Repeated mental health crisis admissions are seldom a matter of patient choice. They come from a combination of system failures, life circumstances, and the nature of the illness itself.
Role of Treatment Nonadherence
One of the biggest reasons chronic psychiatric crisis patients are rehospitalized is difficulty maintaining proper medication usage or not taking it consistently from the outset.
This is true across all major mental health conditions, though some, like schizophrenia, have rates of treatment nonadherence of up to 80 percent.[8]
Similarly, more than half of people with bipolar disorder discontinue their medication within six months of getting treatment.[8]
But it isn’t an issue of not wanting to take medication. Instead, people with severe psychiatric disorders might stop because the medication has significant side effects or because they feel better and conclude they no longer need the medication.[8][9]
In some cases, the complexity of the medication regimen, difficult-to-understand instructions, and inconvenient timing of medication administration cause people to stop taking their medication properly.[9]
When a person stops taking the medication, symptoms return, but often not immediately. It might take weeks before the full symptoms return, by which point the patient may already be in crisis.[9]
Since each relapse makes the next one more likely, severe mental illness crisis cycles become the norm, not the exception.[10] This is known as revolving door mental health treatment:[5][8][9]
- A crisis leads to hospitalization.
- Hospitalization leads to stabilization and discharge.
- Discharge leads to the same conditions that cause the crisis.
- The cycle repeats.
What makes this cycle so hard to break isn’t just medication, but also the home environment or life situation that the patient returns to.
Social and Systemic Barriers That Sustain the Cycle
One of the most important, yet most frequently failed periods in psychiatric care is moving from inpatient to outpatient treatment. Anywhere from 30–50 percent of discharged psychiatric patients miss their follow-up appointment within the first month. That gap is directly associated with an increased risk of relapse.[11]
Research points to one clear improvement: when inpatient staff communicate frequently with outpatient providers before discharge, the patient is almost three times more likely to attend their first follow-up appointment. However, this communication often doesn’t happen consistently enough.[11]
Life circumstances can make it hard for some patients to stick with their outpatient treatment, too. Homelessness, social isolation, poverty, unemployment, and a lack of health insurance are all significant barriers that contribute to repeated psychiatric crises.
Stigma about mental illness is also a factor. Patients might feel blamed, rejected, or viewed as dangerous, which can trigger enough psychological stress to trigger a relapse.[9]
The system itself is a problem as well. Deinstitutionalization moved a significant proportion of psychiatric care from long-term hospitals to community-based organizations, but they may not always have the resources or funding necessary to support all those who need it.[5]
The result is a fragmented system that involves brief inpatient stays and community services that are often not adequately equipped to support patients after discharge.[5]
What Does Effective Care Look Like for High-Risk Patients?
High-risk mental health patients need different care. Just stabilizing patients and discharging them without adequate follow-up can cause particular difficulties for this group.
Research suggests that proactive, whole-person care is more effective because it keeps patients connected to their providers between crises, not just during them.[12] That starts with rethinking where crisis care happens.
Crisis Stabilization and Alternatives to the ER
Crisis stabilization for mental health in adults works best when it is accessible and designed specifically for psychiatric needs. However, emergency mental health visits frequently fail to provide the appropriate care or accessibility. There is often:
- A lack of space.
- Shortages in psychiatric staff.
- An environment that isn’t conducive to recovery.
In some cases, someone with a mental health crisis might wait hours for assistance in an environment that’s loud, chaotic, and actively distressing.[3][13]
One alternative is walk-in crisis stabilization centers. These facilities are open all day, every day, don’t require an appointment, and there is no obligation to pay. For people who need immediate help, that accessibility matters.
Research supports this approach, with crisis stabilization centers associated with a nearly three percent reduction in mental health-related ER visits. The effect is even stronger in rural areas where there are fewer alternatives for quality mental healthcare.[13]
More broadly, crisis intervention programs, such as mobile mental health teams that reach out to those without stable housing, reduce repeat hospitalizations while increasing patient satisfaction.[14]
These programs don’t just address the current emergency; they aim to stabilize the patient, learn what triggered the crisis, and, perhaps most importantly, connect the patient with appropriate follow-up care to try and prevent repeated crises from happening.[15]
Crisis stabilization addresses the current emergency well. But what happens in the months after the crisis matters just as much.
Care Management and Coordinated Outpatient Support
In recent years, complex psychiatric care management has become one of the most studied approaches for people with intensive mental health care needs.
The idea is that one provider, ideally someone with clinical training, guides the patient through every stage of their care. The care manager:[16]
- Helps with medication adherence.
- Connects patients to social services.
- Provides education about the patient’s condition and treatment options.
Research shows this approach can help people spend fewer days in the hospital for psychiatric care.[16]
Collaborative Care Model
Taking things a step further, the Collaborative Care Model (CCM) embeds care management inside a primary care or outpatient setting. A multidisciplinary team then provides comprehensive mental health services. Critically, the CCM tracks its entire patient population, monitoring who isn’t improving and reaching out before things escalate into crisis, thereby reducing psychiatric hospital admissions.[17]
The CCM uses targeted treatments that are supported by research. When patients don’t meet their goals, the CCM team adjusts its approach accordingly, which is a level of care and accountability that is often absent from the standard care most people with a serious mental illness currently receive.[17]
Individualized Care Plans
Another effective approach is using Individualized Care Plans (ICPs), which consolidate every known fact about a patient, from their diagnoses to their social circumstances to treatment recommendations.
Having all that information in a single document available to every provider who works with them has shown great promise for reducing emergency mental health care visits. One study of 190 high utilizers found that the ICP approach reduced ER visits by more than half and saved nearly $41 million.[7]
These savings didn’t come from fragmented or denied care. Rather, outpatient visits increased as inpatient visits decreased. With more appropriate, less intensive care, the patients:[7]
- Showed more improvement in their mental health.
- Were more stable.
- Needed less frequent intensive care.
All of these approaches share a common thread: they work best when they’re part of a sustained, long-term care plan.
Long-Term Planning Is the Missing Piece
Crisis care for mental health patients will always be needed. But for high utilizers of psychiatric care, it is rarely enough. Long-term psychiatric care planning has to be part of the solution. When patients have a long-term, comprehensive plan that follows them across providers, care improves, and the burden on the healthcare system decreases.[7][11]
Building a Continuum of Care That Holds
Reducing psychiatric hospital readmissions requires more than long-term planning. The discharge process, for example, cannot just be paperwork. It should be a clinical intervention in its own right, in which patients and providers communicate openly about what’s going well, what isn’t, and what to do about it.[11]
That process is especially important for patients who aren’t connected to outpatient care prior to being admitted for treatment and who are returning to the same environment that contributed to the crisis in the first place.[18]
Psychiatric care that works in the long term also requires addressing other factors, such as:[19]
- Housing.
- Social isolation.
- Physical health conditions.
- Unemployment.
It means being proactive between crises, too: checking in, monitoring for early warning signs, and adjusting care as needed. Connecting patients with peer mentors, helping them find work, and stable housing are all essential parts of long-term recovery.[5][17]
For people caught up in frequent psychiatric hospitalizations (and for their loved ones), there is genuine hope: this cyclical pattern of hospitalizations isn’t inevitable, and it isn’t permanent, either.
What breaks the cycle often isn’t a single intervention, but a coordinated and relationship-based approach that addresses the patient’s holistic needs and stays engaged with them between crises, not just during them.
Mission Connection is here to help you or your loved one take the next steps towards an improved mental well-being.
Get Long-Term Mental Health Care With Mission Connection
If you or someone you love is dealing with one mental health crisis after another, and it feels like the system isn’t able to provide real stability, Mission Connection offers comprehensive mental health care designed to meet people where they are.
Our outpatient mental health treatment programs are offered in a variety of formats to provide flexibility. Choose from in-person treatment at our locations in California, Virginia, and Washington, virtual telehealth, or a hybrid approach that blends in-person and virtual care.
Our team of experienced clinicians works with people with complex psychiatric needs and builds the kind of long-term care plan that makes lasting recovery possible. We understand that recovery might not look the same for everyone. This is why we design personalized treatment plans that address your individual needs.
If you’d like to learn more about how we can support you, reach out to us online or call us at 866-833-1822. Our caring team will help you find the right treatment for the challenges you’re experiencing and help you gain the skills needed to overcome them.
