{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,9,8]],"date-time":"2025-09-08T06:25:23Z","timestamp":1757312723020,"version":"3.37.3"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"11-12","funder":[{"DOI":"10.13039\/100017101","name":"VA National Center for Patient Safety","doi-asserted-by":"publisher","award":["PSCI-WRJ-Shiner"],"award-info":[{"award-number":["PSCI-WRJ-Shiner"]}],"id":[{"id":"10.13039\/100017101","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000738","name":"U.S. Department of Veterans Affairs","doi-asserted-by":"publisher","award":["MHBC-007-19F"],"award-info":[{"award-number":["MHBC-007-19F"]}],"id":[{"id":"10.13039\/100000738","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,11,3]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n               <jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>Veteran populations are frequently diagnosed with mental health conditions such as substance use disorder and PTSD. These conditions are associated with adverse outcomes including a higher risk of suicide. The Veterans Health Administration (VHA) has designed a robust mental health system to address these concerns. Veterans can access mental health treatment in acute inpatient, residential, and outpatient settings. Residential programs play an important role in meeting the needs of veterans who need more structure and support. Residential specialty types in the VHA include general mental health, substance use disorder, PTSD, and homeless\/work programs. These programs are affiliated with a DVA facility (i.e., medical center). Although residential care can improve outcomes, there is evidence that some patients are discharged from these settings before achieving the program endpoint. These unplanned discharges are referred to using language such as against medical advice, self-discharge, or irregular discharge. Concerningly, unplanned discharges are associated with patient harm including death by suicide. Although there is some initial evidence to locate factors that predict irregular discharge in VHA residential programs, no work has been done to examine features associated with irregular discharge in each residential specialty.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We conducted a retrospective cohort study of patients who were discharged from VHA residential treatment programs between January 2018 and September 2022. We included the following covariates: Principal diagnosis, gender, age, race\/ethnicity, number of physical health conditions, number of mental health diagnostic categories, marital status, risk of homelessness, urbanicity, and service connection. We considered two discharge types: Regular and irregular. We used logistic regression to determine the odds of irregular discharge using models stratified by bed specialty as well as combined odds ratios and 95% CIs across program specialties. The primary purposes are to identify factors that predict irregular discharge and to determine if the factors are consistent across bed specialties. In a secondary analysis, we calculated facility-level adjusted rates of irregular discharge, limiting to facilities with at least 50 discharges. We identified the amount of residual variation that exists between facilities after adjusting for patient factors.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>A total of 279 residential programs (78,588 patients representing 124,632 discharges) were included in the analysis. Substance use disorder and homeless\/work programs were the most common specialty types. Both in the overall and stratified analyses, the number of mental health diagnostic categories and younger age were predictors of irregular discharge. In the facility analysis, there was substantial variation in irregular discharge rates across residential specialties even after adjusting for all patient factors. For example, PTSD programs had a mean adjusted irregular discharge rate of 15.3% (SD: 7.4; range: 2.1\u201331.2; coefficient of variation: 48.4%).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Irregular discharge is a key concern in VHA residential care. Patient characteristics do not account for all of the observed variation in rates across residential specialty types. There is a need to develop specialty-specific measures of irregular discharge to learn about system-level factors that contribute to irregular discharge. These data can inform strategies to avoid harms associated with irregular discharge.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/milmed\/usad131","type":"journal-article","created":{"date-parts":[[2023,5,11]],"date-time":"2023-05-11T16:28:48Z","timestamp":1683822528000},"page":"e3657-e3666","source":"Crossref","is-referenced-by-count":2,"title":["An Analysis of Irregular Discharges From Residential Treatment Programs in the Department of Veterans Affairs Health Care System"],"prefix":"10.1093","volume":"188","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5967-0883","authenticated-orcid":false,"given":"Natalie B","family":"Riblet","sequence":"first","affiliation":[{"name":"Mental Health, White River Junction VA Healthcare System , White River Junction, VT 05009, USA"},{"name":"Psychiatry, Geisel School of Medicine at Dartmouth College , Hanover, NH 03755, USA"},{"name":"Dartmouth Institute, Geisel School of Medicine at Dartmouth College , Hanover, NH 03755, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel J","family":"Gottlieb","sequence":"additional","affiliation":[{"name":"Mental Health, White River Junction VA Healthcare System , White River Junction, VT 05009, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1623-8841","authenticated-orcid":false,"given":"Brian","family":"Shiner","sequence":"additional","affiliation":[{"name":"Mental Health, White River Junction VA Healthcare System , White River Junction, VT 05009, USA"},{"name":"Psychiatry, Geisel School of Medicine at Dartmouth College , Hanover, NH 03755, USA"},{"name":"Dartmouth Institute, Geisel School of Medicine at Dartmouth College , Hanover, NH 03755, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lisa","family":"Zubkoff","sequence":"additional","affiliation":[{"name":"Division of Preventive Medicine in the Department of Medicine, University of Alabama at Birmingham Marnix E. Heersink School of Medicine , Birmingham, AL 35233, USA"},{"name":"Associate Director for Research, Birmingham\/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center (GRECC) , Birmingham, AL 35233, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Korie","family":"Rice","sequence":"additional","affiliation":[{"name":"Mental Health, White River Junction VA Healthcare System , White River Junction, VT 05009, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bradley V","family":"Watts","sequence":"additional","affiliation":[{"name":"Mental Health, White River Junction VA Healthcare System , White River Junction, VT 05009, USA"},{"name":"Psychiatry, Geisel School of Medicine at Dartmouth College , Hanover, NH 03755, USA"},{"name":"Clinical Director, VA Office of Rural Health , White River Junction, VT 05009, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brett","family":"Rusch","sequence":"additional","affiliation":[{"name":"Psychiatry, Geisel School of Medicine at Dartmouth College , Hanover, NH 03755, USA"},{"name":"Leadership Team, White River Junction VA Healthcare System , White River Junction, VT 05009, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2023,5,11]]},"reference":[{"issue":"4","key":"2023110723500873000_R1","doi-asserted-by":"publisher","first-page":"492","DOI":"10.1007\/s10865-020-00176-9","article-title":"Recent trends in the rural-urban suicide disparity among veterans using VA health care","volume":"44","author":"Shiner","year":"2020","journal-title":"J Behav Med"},{"key":"2023110723500873000_R2","doi-asserted-by":"publisher","first-page":"69","DOI":"10.2147\/SAR.S116720","article-title":"Substance use disorders in military veterans: prevalence and treatment challenges","volume":"8","author":"Teeters","year":"2017","journal-title":"Subst Abuse Rehabil"},{"author":"Department of Veterans Affairs","key":"2023110723500873000_R3","article-title":"National suicide data appendix"},{"key":"2023110723500873000_R4","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1017\/S0033291722000617","article-title":"Prevalence, correlates, and mental health burden associated with homelessness in U.S. military veterans","author":"Nichter","year":"2022","journal-title":"Psychol Med"},{"article-title":"Evaluation of the Department of Veterans Affairs Mental Health Services","year":"2018","author":"National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee to Evaluate the Department of Veterans Affairs Mental Health Services","key":"2023110723500873000_R5"},{"author":"Stewart","key":"2023110723500873000_R6","article-title":"State residential treatment for behavioral health conditions: regulation and policy environmental scan"},{"key":"2023110723500873000_R7","article-title":"Mental Health Residential Rehabilitation Treatment Program. 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