INTELLECTUAL AND DEVELOPMENTAL DISABILITIES ÓAAIDD

2019, Vol. 57, No. 2, 127–145 DOI: 10.1352/1934-9556-57.2.127

Predictors of Emergency Room and Hospital Utilization Among

Adults With Intellectual and Developmental Disabilities (IDD)
Meghan G. Blaskowitz, Brigida Hernandez, and Paul W. Scott

Abstract
Emergency room (ER) and hospital utilization among people with intellectual and developmental
disabilities (IDD) are significant contributors to rising healthcare costs. This study identifies
predictors of utilization among 597 adults with IDD. Using a retrospective survey of medical charts,
descriptive statistics and logistic regressions were conducted. Individual-level risk factors for ER
utilization included age, number of chronic health conditions, a diagnosis of cerebral palsy or
neurological disorder, mental illness, and polypharmacy. Environmental predictors included
community-based supported living. Hospitalization predictors included age and number of chronic
illnesses. People residing in group homes were less likely to be admitted. This study found risk
factors unique to individuals with IDD that should be addressed with tailored interventions as states
transition to Medicaid managed care.
Key Words: intellectual and developmental disabilities; emergency room; hospitalization;
services utilization

People with developmental disabilities (DD) expe-
rience lifelong cognitive and/or physical delays,
with typical onset prior to age 22 (National
Institutes of Health, 2010). While some develop-
mental disabilities involve physical issues (e.g.,
cerebral palsy), many people with developmental
disabilities experience concurrent intellectual dis-
ability. An intellectual disability (ID) is one type of
developmental disability, characterized by signifi-
cant limitations in cognitive functioning and
decreased adaptive behavior in social, conceptual,
and practical daily life skills (American Associa-
tion on Intellectual and Developmental Disabilities
[AAIDD], 2017). People with intellectual disability
make up approximately 1% of the population
worldwide (McKenzie, Milton, Smith, & Ouel-
lette-Kuntz, 2016). Due to the high percentage of
people diagnosed with both intellectual disability
and developmental disabilities, the broad term of
‘‘intellectual and developmental disabilities’’, or
IDD, is commonly used to describe the population
of people who receive publicly funded services and
supports from local provider agencies (Braddock,
Hemp, Tanis, Wu, & Haffer, 2017). For the
purposes of this study, participants are described
as people with IDD because of the strong
relationship between DD and ID in the study
sample (i.e., 99.5% of study participants were
diagnosed with at least one developmental disabil-
ity, with the majority (56%) having a co-occurring
intellectual disability).
Given advances in technology and preventa-
tive health care, people with intellectual and
developmental disabilities (IDD) are living longer
(Heller, Stafford, Davis, Sedlezky, & Gaylord,
2010; Office of the Surgeon General, National
Institute of Child Health and Human Develop-
ment, Centers for Disease Control and Prevention,
& U.S. Department of Health and Human
Services, 2002). In addition, over the last 40 years,
people with IDD in the United States (U.S.) have
transitioned from living in institutions to living and
working in more integrated community settings.
Deinstitutionalization was hastened by the 1999
Supreme Court ruling, Olmstead v. L.C., which
brought about rapid closures of congregate settings
(ADA.gov, n.d.). Between 1997 and 2009, 36.2%
of adults with disabilities moved from institutional
settings to less restrictive, community settings like
group homes and supported apartments (Healthy
People 2010, 2010). The need for community-
based housing options among people with IDD has

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2019, Vol. 57, No. 2, 127–145
rapidly increased and has compounded the demand
for community-based healthcare and long-term
services and supports (LTSS; Medicaid, 2013;
Office for People with Developmental Disabilities
[OPWDD], 2013).
People with IDD are often excluded from U.S.
national health surveillance data and not always
recognized as a disparate population (National
Council on Disability, 2009). However, people
with IDD have more complex medical, mental
health, and behavioral health needs than those in
the general population. These chronic health
disparities require frequent medical care and
monitoring (Havercamp, Scandlin, & Roth,
2004) and contribute to earlier mortality among
people with IDD when compared to those without
IDD (O’Leary, Cooper, & Hughes-McCormack,
2018). A study by Straetmans, van Schrojenstein
Lantman-de Valk, Schellevis, & Dinant, (2007)
compared people with intellectual disabilities to
matched controls without IDD and found that
those with IDD experienced a variety of health
problems to a greater degree than the controls.
These health disparities included higher prevalence
rates of epilepsy, skin diseases, diabetes, and upper
respiratory infections. People with cerebral palsy
(CP) are also more likely to experience gastroin-
testinal issues, low bone density, fractures, decubiti,
and chronic muscle tone abnormalities (Evenhuis,
Henderson, Beange, Lennox, & Chicoine, 2000).
Similarly, people with Down syndrome are at
greater risk for chronic health conditions including
congenital heart defects, epilepsy, gastrointestinal
issues, and endocrine disorders. Early onset age-
related disorders such as dementia and visual and
hearing loss are also frequent among people with
Down syndrome (Evenhuis et al., 2000).
Some chronic conditions experienced by
people with IDD can be attributed to modifiable
health behaviors and environmental risk factors
(Haveman et al., 2010). Hsieh, Heller, Bershada-
sky, and Taub (2015) and Stancliffe et al. (2011)
found that physical activity and obesity rates
differed by living arrangement; people with IDD
who lived in independent, community-based set-
tings were more sedentary than those residing in
institutional settings. High rates of obesity put
people with IDD at greater risk for debility and
obesity-related diseases such as coronary artery
disease, hypertension, and diabetes (Evenhuis et al.,
2000; Haveman et al., 2010). Furthermore, studies
have indicated that 30-40% of people with IDD
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also have co-occurring psychiatric disabilities
(Cooper, Smiley, Morrison, Williamson, & Allan,
2007; Einfeld, Ellis, & Emerson, 2011; Emerson,
2003; Morgan, Leonard, Bourke, Jablensky, 2008).
Long-term services and supports for people
with IDD are largely funded through the Medicaid
program. People with disabilities in the U.S. utilize
more Medicaid dollars than any other population
served. Since 2006, Medicaid expenditures have
increased 2-3% annually (Kaiser Family Founda-
tion, 2015) and reached $420 billion of all national
health expenditures in 2012 (Centers for Medicare
and Medicaid Services (CMS), 2011). Although
people with disabilities comprised only 18% of
Medicaid enrollees in 2010, they accounted for
44% of Medicaid’s total expenditures (Centers for
Medicare and Medicaid Services (CMS), 2010).
The state of New York utilizes more Medicaid
dollars than any other state in the nation (U.S.
House of Representatives, 2013). A growing
portion of this cost is due to avoidable emergency
room visits and hospital admissions. One analysis of
utilization among New York’s Medicaid population
found that 60% of ER visits and 16% of hospital
admissions in 2011 were potentially avoidable.
These avoidable utilization costs totaled $1.2
billion in expenditures (New York State Depart-
ment of Health, n.d.).
Research on hospital utilization among adults
with IDD is limited and outdated. A recent
systematic review by Dunn, Hughes-McCormack,
and Cooper (2018) found an overall lack of
research on hospital admissions for physical condi-
tions among people with IDD. From more than
29,000 articles retrieved, their research team found
only three articles that met their inclusion criteria
and gathered data on hospital admission rates due
to general medical or physical conditions among
adults with IDD. The vast majority of articles
reviewed were not from the current decade and
focused solely on psychiatric hospital admissions. A
2006-2008 U.S. Medical Expenditure Panel Survey
of community-based residents (n ¼ 53,586) found
that people with a variety of disabilities accounted
for 40% of annual visits to the emergency room
(Rasch, Gulley & Chan, 2013). Walsh, Kastner,
and Criscione (1997) analyzed data for people with
and without IDD admitted to a New Jersey hospital
between 1983 and 1991 and found that utilization
remained constant for the general population;
however, admissions for children and adults with
IDD rose by 56% and inpatient length of stay
Predictors of Emergency Room Utilization
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2019, Vol. 57, No. 2, 127–145
increased by 42%. As a result, associated healthcare
expenditures for people with IDD grew by 206%,
twice the rate of growth for those in the general
population (Walsh et al., 1997). Another U.S.
study by Janicki et al. (2002) surveyed 1,371 people
with IDD residing in group homes in upstate New
York and found that 30% had used the ER and 16%
had been hospitalized during the prior year.
New York and many other states are currently
seeking transition of their IDD service systems to
Medicaid managed care rather than remaining with
the traditional fee-for-service payment structure.
Although managed care has been widely used as a
mechanism for controlling healthcare costs in
programs for the general public, it has not been
used extensively in systems serving people with
IDD. This newer model of care utilizes needs-based
funding, in which states determine a per member
per month (PMPM) capitated rate to cover an
individual’s supports and services based on assessed
risk levels (Engquist, Johnson, & Johnson, 2012).
Some states have already demonstrated managed
care cost savings through prevention and reduc-
tion of emergency room (ER) visits, hospital
admissions, and hospital lengths of stay (The
Lewin Group, 2004). Yamaki, Wing, Mitchell,
Owen, and Heller (2017) analyzed the impact of
Medicaid managed care on adults with IDD who
received managed care (n ¼ 1121) in the state of
Illinois and those who did not (n ¼ 1102).
Preliminary findings demonstrated a significant
decrease in utilization of the emergency room for
those who received Medicaid managed care
benefits, including care coordination, when com-
pared to those who did not.
The Centers for Disease Control and Preven-
tion (CDC), National Center on Birth Defects and
Developmental Disabilities (NCBDDD) (2009),
and Healthy People 2010 have all acknowledged
the lack of information on the health status, health
needs, and health disparities for people with IDD.
There is great need for more health-related
research on the IDD population (CDC &
NCBDDD, 2009). This study addressed this gap
by examining the health status and hospital
utilization of adults with IDD.
Specific Aims
People with IDD are consistently excluded from
U.S. national health surveillance research (CDC &
NCBDDD, 2009). As a result, little information
M. G. Blaskowitz, B. Hernandez, and P. W. Scott
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exists on health services utilization in this popula-
tion (World Health Organization [WHO], 2013).
This study aimed to identify health trends and
individual and environmental factors that predict-
ed ER utilization and hospitalization for a sample of
adults with IDD who resided in agency-supported
settings throughout New York City, a high
Medicaid recipient-count and cost region (New
York State Department of Health, 2014). Specif-
ically, the study examined: (a) the demographic
characteristics of 597 people with IDD who resided
in agency-supported settings throughout NYC; (b)
associations between sample characteristics (e.g.,
age, mental health status, chronic disease, envi-
ronmental factors) and ER and hospital utilization;
and (c) individual and environmental factors that
predicted ER and hospital utilization (for both
medical and psychiatric reasons).
In an effort to understand the factors that lead
people with IDD to utilize the ER/hospital and
target those factors with interventions, this study
aimed to contribute critical knowledge to the field.
When predictors are known, they can better inform
health models (for example, Accountable Care
Organizations (ACOs) and Medicaid managed care
models) for people with IDD. When programs
provide interventions that target high-need, high-
cost subgroups of people with IDD, cost savings can
be achieved (The Lewin Group, 2004) and funds
redirected to improving quality and access to a
greater array of community-based LTSS options for
people with IDD.
Methods
Participants
Participants were drawn from a group of 744 adults
with IDD who received residential supports from a
large nonprofit provider agency in New York City.
The agency offers a wide range of supports and
services to more than 20,000 people with IDD,
learning disabilities, and physical disabilities across
the lifespan and throughout the greater New York
region. Services are provided to a diverse popula-
tion of people with IDD from all five New York
City boroughs, and three surrounding counties
(Long Island, Suffolk/Nassau counties, and West-
chester county). To meet criteria for this study,
participants had diagnosed intellectual and devel-
opmental disabilities, were 21 years of age and
above, and resided in some form of agency-
supported housing for the entire 2011 calendar
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2019, Vol. 57, No. 2, 127–145
year. Based on these criteria, 597 residents were
included and had their charts reviewed.
Thirty-eight agency nurses were trained to
complete a structured survey of each resident’s
medical chart. The 597 individuals surveyed
resided in one of 94 supported living arrangements
including: (a) intermediate care facilities (ICFs)—
congregate, institutional settings that house ap-
proximately 12-15 people with IDD who require
24-hour daily staff assistance; (b) individualized
residential alternatives (IRAs)—a group home
setting with 4-8 people with IDD receiving 24-
hour daily staff support; or (c) supported apart-
ments—a community-based setting of 1-4 adults
with IDD who are typically more independent and
receive a lower level of staff support (up to 20
hours/week).
Procedures
A structured survey was designed by the research
department of the agency with input from program
administrators and the lead nurse. Four pages in
length, the survey contained 22 items and multiple
sub-items that covered individual and environmen-
tal characteristics. Many responses were multiple
choice and/or frequency-based in nature. The
following independent variables were collected
using the survey and examined as potential
predictors of ER utilization and hospitalization:
age, sex, developmental disability (identified based on
diagnostic information drawn from the Develop-
mental Disabilities Profile-2 (OPWDD, n.d.), a
New York State needs assessment completed by a
team of healthcare professionals including a
physician, pediatrician, psychiatrist and/or psychol-
ogist), level of intellectual disability, chronic health
problems (identified by physician and/or specialist
evaluations and documentation on the active
treatment/monitoring of 20 different diagnosed
health conditions), mental health diagnoses (deter-
mined by psychiatrist or psychologist evaluations
and treatment notes for mental and/or behavioral
health diagnoses), and polypharmacy (identified as
the total number of prescription medications for
medical/physical issues and psychotropic medica-
tions taken by mouth daily or PRN [as needed]).
Five developmental disability types were provided
on the survey—autism spectrum disorder, cerebral
palsy, Down syndrome, neurological disorder, and
other. Neurological disorder was identified based
on a formal physician diagnosis contained within
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the medical chart (epilepsy was given as one
example for nurses who completed the survey).
More than one developmental disability could be
indicated on the survey, if individuals had multiple
diagnoses. A ‘chronic conditions’ variable was
created as a total count of the number of chronic
health problems a person was being actively
monitored/treated for. Prevalence of cardiovascular
disease and diabetes were identified as separate
independent variables, as they serve as Healthcare
Effectiveness Data and Information Set (HEDIS)
measures, which are regularly monitored as perfor-
mance outcomes in Medicaid managed care models
(National Committee for Quality Assurance
[NCQA], 2017). Although no uniform definition
of polypharmacy exists, the most commonly
reported definition in health sciences literature is
taking five or more medications daily (Masnoon,
Shakib, Kalisch-Ellet, & Caughey, 2017). For this
reason, polypharmacy was entered into the model
as a dichotomous variable (0-4 medications vs. 5 or
more medications).
Environmental characteristics were also col-
lected and analyzed as independent variables
including: supported living arrangement and region.
Due to the racial, ethnic, and socioeconomic
diversity of New York’s geographic regions, six
regions were included as environmental variables of
interest. Although these regions are in close
proximity of each other, socioeconomic status and
access to health care services varies a great deal
between them, with the Bronx being the lowest
socioeconomic region, with a median household
income of 34,299 USD and 30.3% of its population
living in poverty, and Long Island being the
wealthiest, with a median household income of
94,064 USD and only 6.95% of its population
living in poverty (U.S. Census Bureau, 2016;
United Hospital Fund, 2008). Region was included
to serve as an indirect indicator of neighborhood
deprivation and health services access. Cooper et
al. (2011) found that adults with IDD were more
likely to live in economically depressed regions.
They also found that socioeconomic status and
neighborhood deprivation were inversely related to
emergency room utilization. This study’s authors
were interested in looking for similar trends within
an urban U.S. population with IDD.
The study had four dependent variables: ER
use for a medical/physical reason, hospitalization
for a medical/physical reason, ER use for a
behavioral/psychiatric reason, and hospitalization
Predictors of Emergency Room Utilization
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2019, Vol. 57, No. 2, 127–145
for a behavioral/psychiatric reason. Program nurses
collected survey information on the number of ER
visits and hospital admissions for medical and
psychiatric reasons during the 2011 calendar year.
Each ER and/or hospital admission was counted
separately; for example, if an individual visited the
ER and then was admitted to the hospital, one ER
visit and one hospital admission were counted.
Emergency room visits were classified based on the
primary symptoms documented in the medical
chart and on follow-up sub-questions on the survey
(e.g., ‘‘The visit was medically necessary [e.g.,
critical injury/illness required immediate atten-
tion].’’ versus ‘‘Consumer needed to be evaluated,
diagnosed, or stabilized’’). ER visits and hospital
admissions were defined as ‘‘being seen in an ER’’
and ‘‘being hospitalized’’ respectively, but the
survey did not collect additional information on
whom the person was seen by during these visits.
Prior to administration, the survey was pilot
tested and minor revisions were made. In addition,
program nurses attended an in-person training
session at their monthly nurse’s meeting and a
follow-up training webinar on how to complete the
survey. Program nurses reviewed hard copies of
residential medical records to complete the survey.
Upon completion of the survey, data were entered
by two trained administrative assistants. A research
associate reviewed the data and contacted program
nurses when information was missing or unclear.
Data Analysis
To explore the sample’s distributions on the
variables in this study, descriptive statistics are
presented including frequencies and percentages for
categorical predictors, along with means, standard
deviations, skew, and kurtosis for continuous
predictors. Bivariate correlations were explored to
examine the relationships amongst the variables
used in this study. To remediate potential collin-
earity problems, predicting variables exhibiting
high correlations (.500 or above) with other
variables were removed from the regression analy-
ses. One exception, however, was that profound
intellectual disability correlated at 0.522 with
institutionalization, but both were retained as they
conceptually represent separate individual and
environmental factors.
Binomial logistic regression models were used
to identify predictors of each ER utilization and
hospitalization for either medical or behavioral/
M. G. Blaskowitz, B. Hernandez, and P. W. Scott
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psychiatric reasons. These outcomes were respec-
tively coded as: 0 for ‘‘No Hospital Admission’’ and
1 for ‘‘Hospital Admission’’; and 0 for ‘‘No ER
utilization’’ and 1 for ‘‘ER utilization’’. In order to
control for the effects of environmental factors
when exploring individual characteristics, models
were built hierarchically. Specifically, environmen-
tal factors (including type of living arrangement
and the region in which participants resided) were
entered in the first block, then individual charac-
teristic (including age, sex, level of intellectual
disability, type of developmental disability, number
of chronic health conditions, mental health
diagnosis, and polypharmacy) were added in a
second block. The regions used in this study
systematically differ from one another in terms of
wealth and demographic composition. To account
for variation due to clustering within region,
regional indicators were entered as fixed-effects
(Allison, 2009). The Queens region was used as the
reference group as it had the largest share of the
sample and a median household income that was
closest to the middle. Regression coefficients (B)
for each of the predicting variables were tested for
statistical significance, and the corresponding odds
ratios (OR [eB]) were used for interpreting effect
size. Odds ratio values of 1.44, 2.48, and 4.27
correspond to Cohen’s d values of 0.2, 0.5, and 0.8
respectively (Borenstein, Hedges, Higgins, &
Rothstein, 2009). Within social sciences literature,
these have come to be conventionally interpreted
as representing small, medium, and large effects on
the suggestion of Cohen (1988). However, it
should be noted that Cohen’s d is a treatment
effect size and may not be appropriate when
considering the prediction of odds from a contin-
uous predictor. There were five missing responses to
items on the survey. Listwise deletion was used
when running the models; hence, these cases were
not included in the analyses.
Results
Table 1 provides descriptive statistics of the
individual and environmental characteristics of
the study’s sample. As seen in Table 1, more than
half of the sample was male (58%), 41 years of age
and above (52%), and had mild to moderate
intellectual disability (ID) (69%). Approximately
one-third of the sample (30%) was diagnosed with
two or more developmental disabilities. Thirty-five
percent (35%) had a neurological developmental
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Table 1 Table 1
Sample Demographics (n ¼ 597) Continued

Total Sample Total Sample

Individual Characteristics (n ¼ 597) Individual Characteristics (n ¼ 597)
Age, mean (SD), skew [kurtosis] 49.0 (13.3), Region, n (%)
0.120 [0.619] Bronx 60 (10.1)
Youth: 18-24 years, n (%) 14 (2.3) Brooklyn 110 (18.4)
Young Adult: 25-44 years 214 (35.8) Long Island 108 (18.1)
Mid-Life: 45-64 years 287 (48.1) Manhattan 90 (15.1)
Late Life: 65 years and above 82 (13.7) Queens 115 (19.3)
Sex, n (%) Westchester 114 (19.1)
Female 250 (41.9) Note. DD ¼ developmental disability; ID ¼ intellectual
disability.
Male 347 (58.1)
Type of DD, n (%) disability, followed by autism (20%) and cerebral
Autism Spectrum Disorders 117 (19.6) palsy (10%). Additionally, a number of participants
Cerebral Palsy 60 (10.1) had concomitant mental illness: 23% had a mood,
Down Syndrome 50 (8.4) adjustment or obsessive-compulsive disorder, 21%
Neurological Disorder 209 (35.0) had an impulse control or intermittent explosive
Other 357 (59.8) disorder and 19% experienced anxiety. High rates
of polypharmacy also existed, with 80% using at
Level of ID, n (%) least five or more medications. Almost everyone in
None/Unspecified 15 (2.5) the sample received primary care (100%) and
Mild 252 (42.2) dental services (99%) during the 2011-2012
Moderate 158 (26.5) calendar year. Many individuals also received at
Severe 87 (14.6) least one type of specialty care (99%) or rehabil-
Profound 85 (14.2) itation service (60%). Ninety-nine percent (99%)
were Medicaid beneficiaries, while 74% had dual
Chronic Conditions, n (%) Medicare coverage. Most participants lived in
Cardiovascular, n (%) 202 (33.8) community-based group homes (63%) and were
Diabetes, n (%) 53 (8.9) sampled across different regions of New York City.
Number of chronic conditions, 2.6 (1.8), From the 2015 U.S. Census, the Bronx region had a
mean (SD), skew [kurtosis] 1.337 [0.453] median household income of 34,299 USD with a
poverty rate at 30.3%, the Brooklyn region had a
Mental Illness, n (%)
median household income of 48,201 USD with a
None 188 (31.5) poverty rate at 22.3%, the Manhattan region had a
1 or more mental illness 409 (68.5) median household income of 72,871 USD with a
Polypharmacy, n (%) poverty rate at 17.6%, the Queens region had a
median household income of 57,720 USD with a
None 8 (1.3)
poverty rate of 13.9%, the Westchester region had
1-2 medications 45 (7.5)
a median household income of 83,958 USD with a
3-4 medications 63 (10.6) poverty rate of 10.1%, and the Long Island region
5 or more medications 481 (80.6) (comprised of Nassau-Suffolk counties) had a
Supported Living Arrangement, median household income of 94,064 USD with a
n (%) poverty rate at 6.95% (U.S. Census Bureau, 2016).
Table 2 presents bivariate correlations. To make
Institutional Setting 191 (32.0)
the correlation matrix (Table 2) more succinct,
Group Home 375 (62.8)
poverty rate is used to proxy regionality.
Supported Living 31 (5.2)
Logistic regressions were conducted to explore
(Table 1 continued) individual and environmental characteristics as

132 Predictors of Emergency Room Utilization

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2019, Vol. 57, No. 2, 127–145
independent predictors of: (a) ER visits for medical
reasons; (b) hospital admission for medical reasons;
(c) ER visits for behavioral/psychiatric reasons; and
(d) hospital admission for behavioral/psychiatric
reasons. Tables 3 and 4 highlight significant
predictors of medical ER visits and hospital
admissions (Table 3) and behavioral/psychiatric
ER visits and hospital admissions (Table 4).
A number of individual and environmental-
level factors were found to be predictive of ER visits
for medical reasons. Both region of residence and
type of living arrangement had a significant impact
on ER utilization for medical reasons. In the second
poorest region, Brooklyn, residents appeared to
have half the odds of visiting the ER for a medical
issue (B ¼ .672, OR ¼ .51, p ¼ .03). This may be
due to the fact that residents here had a lower
average number of chronic conditions than those in
the middle-income region (Queens), which served
as the reference group. Once individual character-
istics were entered, this effect fell to trend
(B¼0.554, OR ¼ 0.557, p ¼ 0.100). Additionally,
when individual characteristics were entered, the
poorest region, the Bronx, exhibited a trend
implying that residents in that region had nearly
twice the odds of visiting the ER for medical
reasons than their counterparts in a more middle-
income region (Queens) (B ¼ 0.642, OR ¼ 1.901, p
¼ 0.076). Residing in a supported apartment was
also associated with increased odds of ER visits for a
medical issue. When considering environmental
factors alone, analysis shows that people residing in
supported living had about 2.6 times the odds for
visiting an ER than those who resided in a group
home (B ¼ .951, OR ¼ 2.59, p ¼ .03). Upon
entering individual-level characteristics, this effect
increased to nearly three times the odds (B ¼ 1.046,
OR ¼ 2.85, p ¼ .03), implying a possible suppression
effect resulting from an association between
residence type and individual-level characteristics.
The following individual-level characteristics
were found to be predictive of ER utilization: each
additional year of age (B ¼ .019, OR ¼ 1.02, p ¼
.02) led to a higher odds of utilizing the ER; having
cerebral palsy (B ¼ .810, OR ¼ 2.25, p ¼ .01) or a
neurological condition (B ¼ .440, OR ¼ 1.55, p ¼
.05) (relative to those having no diagnosed
developmental disability) had higher odds of ER
utilization; ER visit odds increased with each
additional chronic condition (B ¼ .121, OR ¼
1.13, p ¼ .04); those with a mental illness (B ¼ .562,
OR ¼ 1.75, p ¼ .01) had higher odds of ER
M. G. Blaskowitz, B. Hernandez, and P. W. Scott
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utilization than those without a mental illness; and
people who used five or more medications (poly-
pharmacy; B ¼ .787, OR ¼ 2.20, p ¼ .01) had higher
odds for ER utilization than those who took 0-4
medications.
As age increased, the odds of visiting the ER
for a medical reason increased by 2% for each
additional year (B ¼ .019, OR ¼ 1.02, p ¼ .02).
Those with cerebral palsy (B ¼ .810, OR ¼ 2.25, p ¼
.01) had over twice the odds of visiting the ER,
while those with neurological disorders (B ¼ .440,
OR ¼ 1.55, p ¼ .05) had over one and a half higher
odds of visiting the ER than those without a
developmental disability.
Chronic illness and polypharmacy were signif-
icant predictors of ER visits for medical reasons,
with a 13% increase in odds for each additional
chronic illness (B ¼ .121, OR ¼ 1.13, p ¼ .04) and
those on 5 or more medications had over twice the
odds of visiting the ER for medical reasons (B ¼
.787, OR ¼ 2.20, p ¼ .01) than those who took 0 to
4 medications. Having a mental illness was also
significantly associated with going to the ER for
medical issues, with people diagnosed with a
mental illness having 1.75 times higher odds (B ¼
.562, OR ¼ 1.75, p ¼ .01) than those without a
mental health diagnosis.
The results from the regression models exam-
ining predictors of hospitalization for a medical
reason are also detailed in Table 3. When
considering environmental risk factors alone, living
in an institutional setting was the only significant
predictor of hospitalization for a medical reason (B
¼ .497, OR ¼ 1.64, p ¼ .04). When individual-level
factors were added, the prediction fell to non-
significance. It appears that the characteristics of
individuals are explaining the association between
institutional residence and medical hospitaliza-
tions. Namely, as mentioned before, having pro-
found intellectual disabilities has a strong, positive
relationship with institutionalization (r ¼ 0.522).
Among individual-level predictors for medical
hospitalization, age and number of chronic condi-
tions were the only significant factors. The odds of
medical hospitalization increased a factor of 4% for
each additional year in age (B ¼ .037, OR ¼ 1.04, p
¼ .001). For each additional chronic health issue,
the odds of medical hospitalization increased by
about 1.2 times (B ¼ .176, OR ¼ 1.19, p ¼ .02).
Details pertaining to ER visits and hospitaliza-
tion for behavioral/psychiatric reasons are present-
ed in Table 4. There was an effect indicating that
133
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2019, Vol. 57, No. 2, 127–145 DOI: 10.1352/1934-9556-57.2.127

Table 2
Bivariate Zero-Order Correlations Amongst Factors and Outcomes

1 2 3 4 5 6 7 8
1. Poverty Rate 1
2. Institutional Living 0.008 1
3. Supported Living 0.201 0.161 1
4.Age 0.060 0.047 .104 1
5. Sex 0.008 0.051 0.015 0.031 1
6. ASD 0.146 0.177 0.059 0.293 0.136 1
7. CP .143 .141 0.053 .032* 0.032 0.123 1
8. DS 0.043 0.091 0.071 0.045 0.050 0.150 0.101 1
9. Neuro 0.204 0.137 0.077 0.005 0.025 0.036 0.140 0.095
10. Other DD 0.191 0.133 0.146* 0.171 0.003 .0.309 0.169 0.221
11. Moderate ID 0.064 0.200 0.089 0.042 0.032 0.096 0.002 0.024
12. Severe ID 0.035 0.409 0.097 0.069 0.073 0.167 0.004 0.132
13. Profound ID 0.004 0.522 0.095 0.002 0.015 .028 0.135 0.050
14. Chronic Conditions 0.054 0.003 0.007 0.411 0.039 0.189 0.009 0.032
15. MH diagnosis 0.074 0.014 0.069 0.070 0.005 0.116 0.061 0.094
16. Poly-Pharmacy .023 .044 0.020 .294 .114 0.071 .022 .128
17. ER Behavioral 0.043 0.057 0.007 0.065 0.045 0.005 0.073 0.039
18. Hospital Behavioral 0.036 0.037 0.041 0.017 0.050 0.013 0.059 0.018
19. ER Medical .003 .072 0.033 0.166 0.098 .086 0.114 .089*
20. Hospital Medical 0.031 0.089 0.013 0.211 0.027 0.068 0.059 0.026
1 2 3 4 5 6 7 8
Note. MH ¼ mental health diagnosis; ASD ¼ Autism Spectrum Disorder; CP ¼ cerebral palsy; DS ¼ Down Syndrome; Neuro
¼ neurological disorder; DD ¼ developmental disability; ID ¼ intellectual disability.
*Denotes significance at 0.05.

individuals residing in a wealthier region (West-
chester) had approximately 75% times lower odds
of visiting the ER for behavioral/psychiatric reasons
than individuals living in a more middle-income
region (Queens) (B ¼ 1.353, OR ¼ .26, p ¼ .04).
Once individual-level characteristics are entered,
however, this effect falls to non-significance.
Among individual level characteristics, those with
mental illness diagnoses had nearly 19 times higher
odds of visiting the ER for behavioral/psychiatric
reasons (B ¼ 2.931, OR ¼ 18.75, p ¼ .004) than
those without a mental health diagnosis. No other
factors were significant predictors of ER visits for
behavioral/psychiatric reasons. In this study, no
significant predictors of hospitalization for behav-
ioral/psychiatric reasons were found.
Discussion
Limited health surveillance and utilization data
exist for people with intellectual and developmen-
tal disabilities in the U.S. This study was one of the
first to examine predictors of ER and hospital
utilization for medical and behavioral/psychiatric
reasons. During the study period, 38% of the sample
visited the ER for a medical issue, which was eight
percentage points higher than the utilization rate
(30%) reported in the Janicki et al. (2002) study of
adults with IDD residing in upstate New York group
homes. This ER utilization rate was also higher
than the 2012 published rate for people in the
general U.S. population (20%) (Gindi, Cohen &
Kirzinger, 2012). Although additional research is
needed, this finding suggests that people with IDD
residing in the NYC area may have a unique set of
characteristics that place them at greater risk for
ER utilization.
Further, 15% and 3% of this study’s sample
were admitted to the hospital for medical and
behavioral/psychiatric issues, respectively. Hospital
admission for medical reasons was fairly consistent
with Janicki et al.’s (2002) sample (16%) but lower

134 Predictors of Emergency Room Utilization

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2019, Vol. 57, No. 2, 127–145 DOI: 10.1352/1934-9556-57.2.127

Table 2
Extended

9 10 11 12 13 14 15 16 17 18 19 20

1
0.394 1
0.018 0.004 1
0.095 0.126 0.248 1
0.073 0.037 0.244 0.168 1
0.192 0.010 0.052 0.072 0.021 1
0.089 0.004 0.051 0.065 0.075 0.092 1
0.145 .023 .036* .003 0.017 .339 .254 1
0.033 0.036 0.037 0.008 0.042 0.001 0.177 0.056 1
0.047 0.025 0.005 0.017 0.016 0.013 0.120 0.037 0.633 1
.150 .014 0.067 0.035 .093 0.202 0.127 0.220 0.160 0.043 1
0.088 0.023 0.032 0.011 0.080 0.202 0.034 0.136 0.059 0.034 0.483 1
9 10 11 12 13 14 15 16 17 18 19 20

than the general public’s percentage (27%) (Gindi
et al., 2012). Although speculative, this low rate of
admission may represent the level of preventative
care that residents receive by provider agencies
who often have nurses assigned to group homes.
These nurses are charged with ensuring residents’
medical needs are attended to. The low rate of
behavioral/psychiatric admissions may be due to
misclassification error or unique features of the
sample used in this study (e.g., a low incidence of
hospitalization for behavioral/psychiatric reasons)
and does not imply that this would be the case in a
larger population.
Individual-level predictors of ER/hospital uti-
lization were consistent between this sample, other
samples of adults with IDD, the elderly U.S.
population (e.g., polypharmacy) and general U.S.
population (e.g., age, chronic illness) (Joynt,
Gawande, Orav, & Jha, 2013; Lin et al., 2006;
Wong, Marr, Kwan, Meiyappan, & Adcock, 2014).
Individual-level health factors are often of focus in
utilization studies (Hosking et al., 2017; Thomas et
al., 2011). However, the impact of socioeconomic
and environmental predictors on ER/hospital
utilization rates have rarely been studied (Lin et
al., 2006). Therefore, the environmental predictors
of living arrangement and geographic region were
of great interest in this study. When individual-
level factors were controlled for, the risk of medical
ER utilization intensified for supported apartment
residents, placing them at three times greater odds
for visiting the ER than those residing in group
homes. Lunsky, Balogh and Cairney (2012) found a
similar, yet non-significant, trend in which people
with ID living in the community demonstrated a
greater risk for visiting the ER (for psychiatric
reasons) than group home residents.
Increased risk for ER utilization among adults
with IDD who live in the community may be
attributed to service access issues, low utilization of
primary care and/or preventative wellness appoint-
ments, lack of understanding of IDD-specific needs
among primary care physicians (PCP), less staff
support in encouraging healthy eating, physical
activity and regular health checks, and decreased or
unreliable access to transportation (Friedman &
Rizzolo, 2016; Hsieh et al., 2015; U.S. Public
Health Service, 2005), all of which merit further

M. G. Blaskowitz, B. Hernandez, and P. W. Scott 135

 Table 3
Predictors of ER Use and Hospitalization for a Medical Reason

136
Emergency Room Visits for Medical Reason Hospitalization for Medical Reason
(n ¼ 229) (n ¼ 91)
Step Two Step Two
Step One (Enabling) (Incl. Predisposing) Step One (Enabling) (Incl. Predisposing)
Exp (B) Exp (B) Exp (B) Exp (B)
2019, Vol. 57, No. 2, 127–145

Variables b [95% CI] Sign. b [95% CI] Sign. b [95% CI] Sign. b [95% CI] Sign.
Region
Bronx .186 1.20 [.64, 2.28] .642 1.90 [.94, 3.87] ^ .122 .89 [.37, 2.12] .161 1.18 [.45, 3.06]
Brooklyn .672 .51 [.28, .95] * .554 .58 [.30, 1.11] ^ .064 .94 [.44, 2.01] .013 1.01 [.46, 2.26]
Long Island .273 .76 [.44, 1.32] .094 .91 [.50, 1.67] .381 .68 [.32, 1.47] .183 .83 [.37, 1.88]
Manhattan .133 1.14 [.64, 2.03] .288 1.33 [.71, 2.50] .028 1.03 [.49, 2.16] .064 1.07 [.48, 2.38]
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

Queens Ref Ref Ref Ref Ref Ref Ref Ref

Westchester .181 1.20 [.70, 2.05] .317 1.37 [.76, 2.49] .325 .72 [.35, 1.51] .325 .72 [.33, 1.60]
Living Arrangement
Institutional Setting .271 1.31 [.91, 1.90] .215 .81 [.45, 1.46] .497 1.64 [1.02, 2.66] * .361 1.44 [.68, 3.05]
Group Home Ref Ref Ref Ref Ref Ref Ref Ref
Supported Living .951 2.59 [1.10, 6.11] * 1.046 2.85 [1.12, 7.24] * .076 .93 [.28, 3.08] .149 .86 [.25, 3.00]
Age .019 1.02 [1.00, 1.04] * .037 1.04 [1.02, 1.06] ***
Sex
Female Ref Ref Ref Ref
Male .302 .74 [.51, 1.07] .050 .95 [.59, 1.54]
Type of Developmental
Disability
None Ref Ref Ref Ref
ASD .077 .93 [.52, 1.65] .213 .80 [.36, 1.82]
Cerebral Palsy .810 2.25 [1.18, 4.28] * .433 1.54 [.72, 3.32]
Down Syndrome .602 .55 [.24, 1.23] .346 .71 [.25, 2.00]
Neurological Disorder .440 1.55 [.99, 2.43] * .158 1.17 [.66, 2.09]
Other Developmental .170 1.19 [.73, 1.92] .307 .74 [.40, 1.37]
Disability
ÓAAIDD

Predictors of Emergency Room Utilization

DOI: 10.1352/1934-9556-57.2.127

(Table 3 continued)
 Table 3
Continued

Emergency Room Visits for Medical Reason Hospitalization for Medical Reason
2019, Vol. 57, No. 2, 127–145

(n ¼ 229) (n ¼ 91)
Step Two Step Two
Step One (Enabling) (Incl. Predisposing) Step One (Enabling) (Incl. Predisposing)
Exp (B) Exp (B) Exp (B) Exp (B)
Variables b [95% CI] Sign. b [95% CI] Sign. b [95% CI] Sign. b [95% CI] Sign.
Level of Intellectual
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

Disability

M. G. Blaskowitz, B. Hernandez, and P. W. Scott

None/Mild Ref Ref Ref Ref
Moderate .042 1.04 [.66, 1.66] .033 1.03 [.55, 1.94]
Severe .516 1.68 [.83, 3.38] .149 1.16 [.46, 2.92]
Profound .697 2.01 [.96, 4.21] ^ .354 1.43 [.57, 3.55]
Chronic Health Conditions
Number of chronic .121 1.13 [1.01, 1.27] * .176 1.19 [1.04, 1.37] *
conditions
Mental Illness
None Ref Ref Ref Ref
1 or more mental .562 1.75 [1.14, 2.70] ** .240 1.27 [.73, 2.22]
illness
Polypharmacy
0-4 medications Ref Ref Ref Ref
5 or more medications .787 2.20 [1.21, 3.98] ** .574 1.78 [.69, 4.55]
Note. ^p , .10, *p , .05, **p , .01, ***p , .001.
ÓAAIDD
DOI: 10.1352/1934-9556-57.2.127

137
 Table 4
Predictors of ER Use and Hospitalization for a Behavioral/Psychiatric Reason

138
Emergency Room Visits for Behavioral/ Hospitalization for Behavioral/
Psychiatric Reason (n ¼ 44) Psychiatric Reason (n ¼ 18)
Step Two Step Two
Step One (Enabling) (Incl. Predisposing) Step One (Enabling) (Incl. Predisposing)
Exp (B) Exp (B) Exp (B) Exp (B)
2019, Vol. 57, No. 2, 127–145

Variables b [95% CI] Sign. b [95% CI] Sign. b [95% CI] Sign. b [95% CI] Sign.
Region
Bronx .359 1.43 [.55, 3.75] .284 1.33 [.45, 3.90] .702 .50 [.05, 4.55] 1.039 .35 [.04, 3.52]
Brooklyn .966 .38 [.11, 1.27] .906 .40 [.12, 1.40] .333 .72 [.13, 4.02] .363 .70 [.12, 4.15]
Long Island .218 .80 [.32, 2.00] .184 .83 [.31, 2.22] .295 1.34 [.35, 5.15] .517 1.68 [.40, 7.13]
Manhattan .154 .86 [.32, 2.33] .103 1.11 [.39, 3.19] .397 1.49 [.35, 6.28] .655 1.93 [.42, 8.90]
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

Queens Ref Ref Ref Ref Ref Ref Ref Ref

Westchester 1.353 .26 [.07, .95] * 1.096 .33 [.09, 1.28] ^ .604 .55 [.10, 3.09] .162 .85 [.14, 5.12]
Living Arrangement
Institutional Setting .454 .64 [.30, 1.35] .140 .87 [.28, 2.70] .581 .56 [.18, 1.77] .405 .67 [.12, 3.71]
Group Home Ref Ref Ref Ref Ref Ref Ref Ref
Supported Living .307 1.36 [.24, 7.61] .378 1.46 [.25, 8.64] — — — —
Age .029 .97 [.94, 1.00] ^ .023 .98 [.93, 1.03]
Sex
Female Ref Ref Ref Ref
Male .396 1.49 [.75, 2.97] .667 1.95 [.65, 5.82]
Type of Developmental
Disability
None Ref Ref Ref Ref
ASD .567 .57 [.20, 1.59] 1.361 .26 [.05, 1.43]
Cerebral Palsy 1.343 .26 [.03, 2.14] — —
Down Syndrome .520 .60 [.12, 3.04] 1.070 .34 [.03, 3.97]
Neurological Disorder .447 .64 [.27, 1.53] 1.276 .28 [.06, 1.30] ^
Other Developmental .140 .87 [.35, 2.15] .662 .52 [.11, 2.43]
Disability
ÓAAIDD

Predictors of Emergency Room Utilization

DOI: 10.1352/1934-9556-57.2.127

(Table 4 continued)
 Table 4
Continued
2019, Vol. 57, No. 2, 127–145

Emergency Room Visits for Behavioral/ Hospitalization for Behavioral/

Psychiatric Reason (n ¼ 44) Psychiatric Reason (n ¼ 18)
Step Two Step Two
Step One (Enabling) (Incl. Predisposing) Step One (Enabling) (Incl. Predisposing)
Exp (B) Exp (B) Exp (B) Exp (B)
Variables b [95% CI] Sign. b [95% CI] Sign. b [95% CI] Sign. b [95% CI] Sign.
Level of Intellectual
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

M. G. Blaskowitz, B. Hernandez, and P. W. Scott

Disability
None/Mild Ref Ref Ref Ref
Moderate .579 .56 [.24, 1.32] .004 1.00 [.31, 3.28]
Severe .215 .81 [.24, 2.73] .122 1.13 [.16, 7.87]
Profound .432 .65 [.14, 2.98] .312 1.37 [.15, 12.89]
Chronic Health Conditions
Number of chronic .036 1.04 [.84, 1.28] .071 1.07 [.78, 1.48]
conditions
Mental Illness
None Ref Ref Ref Ref
1 or more mental illness 2.931 18.75 [2.51, 139.88] ** 17.911 —
Polypharmacy
0-4 medications Ref Ref Ref Ref
5 or more medications .577 1.78 [.61, 5.24] .642 1.90 [.36, 9.99]
Note. ^p , .10, *p , .05, ** p, .01.
ÓAAIDD
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139
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2019, Vol. 57, No. 2, 127–145
investigation. People who live more indepen-
dently or with family typically lack necessary
access to medical and/or mental health services
and receive ‘‘light touch’’ supports (Lunsky, Tint,
Robinson, & Khodaverdian, 2011; Weiss, 2009).
Improved access to LTSS for those living in
supported apartments, independently, or with
family is imperative to improving health-related
quality of life and decreasing hospital utilization
in this population.
Geographic region was also identified as a
predictor of ER utilization in this study. The
present study used geographic region as an indirect
indicator of neighborhood deprivation and health
services access. People who resided in the
wealthier region of Westchester utilized the ER
for psychiatric visits to a lesser degree than people
in the middle-income region of Queens. Although
only marginally significant, living in the Bronx,
the lowest socioeconomic region, was a potential
risk factor for both medical and behavioral/
psychiatric ER visits. This is consistent with
outcomes from other utilization studies of people
with disabilities (Cooper et al., 2011; Rasch,
Gulley, & Chan, 2013) and the broader New
York City population (Robert Wood Johnson
Foundation, 2013). Cooper et al.’s (2011) study
of adults with IDD found that people with greater
neighborhood deprivation and less access to ‘goods
and services, resources and amenities, and of a
physical environment which are customary in
society’ (p. 315) utilized less outpatient care and
more emergency services. New York City health
rankings within the general population have
consistently found a greater number of Bronx
residents with poor self-rated health, no insurance,
decreased access to primary care, a higher
prevalence of preventable hospital stays, and
higher rates of psychiatric ER visits than any
other region in New York City. (Robert Wood
Johnson Foundation, 2013; Office of Mental
Health [OMH], 2014).
Clinical Implications
Programmatic and policy-level interventions have
been piloted to improve quality outcomes and
reduce emergency-related cost among people with
IDD. These include patient-centered medical
homes (PCMHs), Accountable Care Organiza-
tions (ACOs) and the IDD-specific behavioral
health intervention, Systemic Therapeutic As-
140
ÓAAIDD
DOI: 10.1352/1934-9556-57.2.127
sessment, Respite and Treatment (START; Cen-
ter for START Services, 2019). U.S. provider
agencies have also undertaken a variety of
organizational level interventions including 24-
hour nursing hotlines, telepsychiatry and tele-
health systems that enable people with IDD and
their staff to contact nurses/physicians after hours
and receive support in deciphering between true
emergencies and preventable or risk-aversive ER
visits. Although some of these initiatives are
targeted towards the general public or other
patient populations, attention must be paid to
their applicability for people with IDD.
Increased access to PCP and specialty provid-
ers, and enhanced training for these professionals in
preventative care for people with IDD, have also
proven effective in reducing ER utilization and
hospitalization. Interventions such as salary and
loan repayment incentives have proven effective in
increasing access to PCPs and specialty outpatient
providers in U.S. Health Professional Shortage
Areas, like the Bronx (National Health Service
Corps, 2014). In Canada, the Health Care Access
Research and Developmental Disabilities (H-
CARDD) Program has developed brief teaching
videos involving actors with intellectual disabili-
ties, a toolkit, and ‘‘About Me Passports’’ describ-
ing each person’s needs in order to improve PCP
and emergency room staff understanding of people
with IDD and optimize the quality of care provided
to them (Lunsky & Canso, n.d.). Training
programs for physicians, such as the Leadership
Education in Neurodevelopmental and Related
Disabilities (LEND) program, prepare them to
address the unique health needs of people with
IDD (Ervin & Merrick, 2014).
Self-management programs for community-
dwelling adults with IDD have also been piloted
to improve health outcomes and decrease ER/
hospital utilization rates. Bazzano et al. (2009)
implemented a 7-month Healthy Lifestyle Change
Program (HLCP) tailored to the needs of people
with IDD. The program included peer mentorship
and biweekly education aimed at improving
knowledge, attitudes, behavior, diet and exercise.
HLCP resulted in weight loss for 75% of its
participants, a number of positive lifestyle changes,
an increase in community capacity and overall
improved quality of life for participants from pre- to
post-intervention.
Predictors of Emergency Room Utilization
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2019, Vol. 57, No. 2, 127–145
Research Implications
Primary limitations of this study include its
retrospective design and use of secondary survey
data. Because the study utilized secondary data,
important social/environmental factors and con-
founders were not accounted for in this analysis, as
they were not collected using the survey tool (e.g.,
additional health conditions and chronic diseases,
race and ethnicity data, socioeconomic status, level
of family involvement, usual source of primary care,
Emergency Severity Index (ESI) or triage scores,
history of ER visits and hospitalizations, informa-
tion on whom the individual was seen by in the
ER). Human error is inherent in a survey based on
medical record reviews. Misclassification and
underreporting of behavioral/psychiatric emergen-
cies may have also occurred. Further, ER visits and
hospitalizations were modeled as being linearly
related to age. Future research could benefit from
exploring potential non-linear relations between
age and these outcomes. In this study, the potential
for interaction effects amongst the predictor
variables was not addressed. Additional studies
exploring potential interactions would serve as
important follow-ups to the research presented
here. Finally, the low incidence rate of hospitaliza-
tions due to behavioral/psychiatric reasons made it
difficult to generate conclusions about predictors of
this outcome.
Future utilization studies should more clearly
define outcomes to aid in delineation between
medical/physical and behavioral/psychiatric events
and further explore specific characteristics unique
to behavioral/psychiatric utilization. The impact of
social determinants of health and environmental
factors, specifically socioeconomic status and living
arrangement (including independent living or
living with family), warrants further investigation.
This study identifies utilization predictors for
an urban sample of people with IDD. With a new
administration, the U.S. is embarking on a critical
period of Medicaid reform for people with IDD,
their families, service providers and state health
systems. The U.S. is challenged to not only contain
healthcare costs, but also provide person-centered
services aimed at closing health disparity gaps for
people with IDD. As New York and other states
across the nation transition to a Medicaid managed
care model, the unique qualities of people with IDD
must be considered when setting risk-adjusted
capitation payments and determining per member
M. G. Blaskowitz, B. Hernandez, and P. W. Scott
ÓAAIDD
DOI: 10.1352/1934-9556-57.2.127
per month rates. Further investigation is needed to
determine the impact of new policy and practice-
level interventions on utilization and health-
related quality of life for one of its most
underserved populations—people with intellectual
and developmental disabilities.
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Predictors of Emergency Room Utilization
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES ÓAAIDD
2019, Vol. 57, No. 2, 127–145 DOI: 10.1352/1934-9556-57.2.127

Yamaki, K., Wing, C., Mitchell, D., Owen, R., Department of Occupational Therapy; Brigida
Heller, T. (2017). The impact of Medicaid Hernandez, YAI Network; and Paul W. Scott,
managed care on emergency department and
University of Pittsburgh, Department of Health
primary car utilization among adults with intellec-
tual and developmental disabilities [PowerPoint and Community Systems.
slides].

Correspondence concerning this article should be

Received 1/21/2018, accepted 5/17/2018. addressed to Meghan G. Blaskowitz, Duquesne
University, Department of Occupational Therapy,
Authors: 600 Forbes Avenue, Pittsburgh, PA 15282 (e-mail:
Meghan G. Blaskowitz, Duquesne University, blaskowitzm@duq.edu).

M. G. Blaskowitz, B. Hernandez, and P. W. Scott 145

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