Needs-oriented discharge planning for high utilisers of psychiatric services: multicentre randomised controlled trial

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text.

MAIN RESULTS

We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants;  low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence).

AUTHORS' CONCLUSIONS

A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.

Care Management for Serious Mental Illness: A Systematic Review and Meta-Analysis

OBJECTIVE

Persons with serious mental illness face adverse psychiatric and medical outcomes, and their care is associated with a large burden of health care costs. Care management, in which assessment, care planning, and care coordination are provided, is a common model of support, yet the evidence supporting its use among psychiatric populations is mixed. A systematic review and a meta-analysis were undertaken to determine the impact of care management on clinical outcomes, acute care utilization, cost, and satisfaction among adults with serious mental illness.

METHODS

A multidatabase literature search was performed. Articles were included if they compared standard outpatient care plus care management with standard outpatient care alone for adults with serious mental illness and reported on one or more predefined outcomes. Randomized controlled trials (RCTs) and other study designs were permitted for inclusion in the systematic review. The meta-analysis included only RCTs.

RESULTS

For the systematic review, 34 articles representing 28 unique studies were included. Fifteen of these articles, representing 12 unique studies, were included in the meta-analysis, which indicated that care management was associated with small, statistically significant improvements in psychiatric symptoms, overall quality of life (QOL), and mental QOL (Hedges' g range 0.13-0.26). In addition, care management was associated with a small, statistically significant reduction in inpatient psychiatric hospital days (Hedges' g=0.16, p=0.02).

CONCLUSIONS

Care management is associated with fewer psychiatric symptoms and greater QOL for persons with serious mental illness. Further work is needed to determine which components of the intervention are associated with effectiveness.

Discharge interventions from inpatient child and adolescent mental health care: a scoping review

The post-discharge period is an extremely vulnerable period for patients, particularly for those discharged from inpatient children and adolescent mental health services (CAMHS). Poor discharge practices and discontinuity of care can put children and youth at heightened risk for readmission, among other adverse outcomes. However, there is limited understanding of the structure and effectiveness of interventions to facilitate discharges from CAMHS. As such, a scoping review was conducted to identify the literature on discharge interventions. This scoping review aimed to describe key components, designs, and outcomes of existing discharge interventions from CAMHS. Nineteen documents were included in the final review. Discharge interventions were extracted and summarized for pre-discharge, post-discharge, and bridging elements. Results of this scoping review found that intervention elements included aspects of risk assessment, individualized care, discharge preparation, community linkage, psychoeducation, and follow-up support. Reported outcomes of discharge interventions were also extracted and included positive patient and caregiver satisfaction, improved patient health outcomes, and increased cost effectiveness. Literature on discharge interventions from inpatient CAMHS, while variable in structure, consistently underscore the role of such interventions in minimizing patient and family vulnerability post-discharge. However, findings are limited by inadequate reporting and heterogeneity across studies. There is a need for further research into the design, implementation, and evaluation of interventions to support successful discharges from inpatient child and adolescent mental health care.

Interventions to improve discharge from acute adult mental health inpatient care to the community: systematic review and narrative synthesis

Background

The transition from acute mental health inpatient to community care is often a vulnerable period in the pathway, where people can experience additional risks and anxiety. Researchers globally have developed and tested a number of interventions that aim to improve continuity of care and safety in these transitions. However, there has been little attempt to compare and contrast the interventions and specify the variety of safety threats they attempt to resolve.

Methods

The study aimed to identify the evidence base for interventions to support continuity of care and safety in the transition from acute mental health inpatient to community services at the point of discharge. Electronic Databases including PsycINFO, MEDLINE, Embase, HMIC, CINAHL, IBSS, Cochrane Library Trials, ASSIA, Web of Science and Scopus, were searched between 2000 and May 2018. Peer reviewed papers were eligible for inclusion if they addressed adults admitted to an acute inpatient mental health ward and reported on health interventions relating to discharge from the acute ward to the community. The results were analysed using a narrative synthesis technique.

Results

The total number of papers from which data were extracted was 45. The review found various interventions implemented across continents, addressing problems related to different aspects of discharge. Some interventions followed a distinct named approach (i.e. Critical Time Intervention, Transitional Discharge Model), others were grouped based on key components (i.e. peer support, pharmacist involvement). The primary problems interventions looked to address were reducing readmission, improving wellbeing, reducing homelessness, improving treatment adherence, accelerating discharge, reducing suicide. The 69 outcomes reported across studies were heterogeneous, meaning it was difficult to conduct comparative quantitative meta-analysis or synthesis.

Conclusions

The interventions reviewed are spread across a spectrum ranging from addressing a single problem within a single agency with a single solution, to multiple solutions addressing multi-agency problems. We recommend that future research attempts to improve homogeneity in outcome reporting.

Discharge planning in mental healthcare settings: A review and concept analysis

To ensure a safe transition of mental health patients from hospital to community settings, greater attention is being given to discharge planning. However, assessing the quality of discharge planning has been challenging due to wide variations in its definition. To facilitate evaluation of discharge planning, its meaning in the mental health literature was systematically explored. This concept analysis is part of a larger study to develop an instrument to measure the quality of discharge planning processes in mental health care. Walker and Avant's (2011) concept analysis approach was adopted to provide a comprehensive definition of discharge planning. Electronic databases and grey literature were searched and analysed according to Grant and Booth's (2009) systematic search and review process. Literature published between 1900 and 2018 was reviewed. Forty-nine articles meeting the inclusion criteria were included in the analysis. Discharge planning is a complex, multifaceted concept with six defining attributes: comprehensive needs assessment; collaborative, patient-centered care; resource availability management; care and service coordination; discharge planner role; and a discharge plan. Discharge planning begins with the initial rapid assessment and symptom stabilization of a patient on admission, coincides with treatment planning, and is associated with hospital readmissions and continuity of care. The mental health literature was reviewed to analyse different interpretations of discharge planning. The conceptual definition provided can assist healthcare providers, organizational leaders, and policymakers to design and implement effective discharge planning policies and guidelines. Providing clarity regarding discharge planning also provides a critical foundation for developing an instrument.

Effectiveness of Transitional Interventions in Improving Patient Outcomes and Service Use After Discharge From Psychiatric Inpatient Care: A Systematic Review and Meta-Analysis

Background: The transition from psychiatric hospital to community is often hindered by challenges that influence community adjustment and continuity of care. Transitional interventions with bridging components are provided prior to discharge and continue beyond inpatient care. They provide continuity of care and may be effective in preventing readmission. We aimed to assess the effectiveness of transitional interventions with predischarge and postdischarge components in reducing readmissions and improving health-related or social outcomes of patients discharged from psychiatric hospitals. Methods: We conducted a systematic review by searching electronic databases (MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, and Psyndex) and included randomized, nonrandomized, and one-group study designs. A random effects meta-analysis was conducted with randomized controlled trials (RCTs) reporting data on readmission rates. Other study designs were synthesized qualitatively. Results: After screening 2,673 publications, 16 studies (10 RCTs, three quasi-experimental, and three cohort studies) were included and nine RCTs were included in the meta-analysis. The tested interventions included components from case management, psychoeducation, cognitive behavioral therapy, and peer support. All studies with significant improvements in at least one outcome provided elements of case management, most frequently in combination with cognitive behavioral therapy and psychoeducation. Readmission rates during follow-up ranged between 13% and 63% in intervention groups and 19% and 69% in control groups. Overall, we found an odds ratio of 0.76 (95% confidence interval = 0.55-1.05) for readmission due to transitional interventions. Heterogeneity was low at only 31% (p = 0.17) and the funnel plot indicated no obvious publication biases. Conclusions: We observed that transitional interventions with bridging components were no more effective in reducing readmission than treatment as usual; however, these results are based on limited evidence. Therefore, additional high-quality research is required to conclude the effectiveness of transitional interventions. Nevertheless, transitional interventions with bridging components are preferred by service users and could be an alternative to strategies regularly employed.

An Attempt to Stem the Tide: Exploring the Effect of a 90-Day Transitional Care Intervention on Readmissions to an Acute Male Psychiatric Unit in South Africa

INTRODUCTION

Pressure on inpatient beds often results in premature discharges, which may precipitate early readmission. This has prompted an increased interest in transitional care interventions to bridge the gap between in- and outpatient care to reduce such readmissions. Our study aimed to assess the effect of a Transitional Care Service (TCS) on readmission rates in a high pressure inpatient service which utilizes a premature discharge policy to address bed pressures.

METHODS

Sixty male patients identified for crisis discharge were offered a TCS for the first ninety days after discharge. Patients received a structured intervention consisting of four phone calls and one home visit, focusing on maintaining adherence, appointment reminders and psychoeducation. The TCS patients were retrospectively compared to a matched control group in terms of readmission after 90days. Data was collected on adherence to medication, attendance of appointments and incidence of substance use.

RESULTS

There was no significant difference in readmission rates. Prevalence of substance use was very high (90%), especially methamphetamine use (48%). Adherence dropped from 45% (n=27) at one week post-discharge to 25% (n=15) at 90days.

CONCLUSION

Structured telephone-based transitional interventions have no effect on readmission rates in this setting. Prematurely discharged patients require more comprehensive support with focus on comorbid substance use.

Outcomes and feasibility of the short transitional intervention in psychiatry in improving the transition from inpatient treatment to the community: A pilot study

Discharge from psychiatric inpatient care is frequently described as chaotic, stressful, and emotionally charged. Following discharge, service users are vulnerable to becoming overwhelmed by the challenges involved in readapting to their home environments, which could result in serious problems and lead to readmission. The short transitional intervention in psychiatry (STeP) is a bridging intervention that includes pre- and post-discharge sections. It aims to prepare patients for specific situations in the period immediately following discharge from a psychiatric hospital. We conducted a quasi-experimental pilot study to determine the feasibility of the intervention, and gain insight into the effects of the STeP. Two inpatient wards at a Swiss psychiatric hospital participated in the study, and represented the intervention and control arms. Patient recruitment and baseline assessment were performed 2 weeks prior to discharge. Follow-up data were collected 1 week subsequent to discharge. Questionnaires measured coping, admission and health-care usage, self-efficacy, working alliance, experience of transition, and the number of difficulties experienced following discharge. Fourteen and 15 patients completed the follow-up assessment in the control and intervention groups, respectively. The STeP did not affect primary or secondary outcomes; however, it was shown to be feasible, and patients' feedback highlighted the importance of post-discharge contact sessions. Further research is required to improve understanding of the discharge experience, identify relevant patient outcomes, and assess the effectiveness of the intervention in an adequately-powered randomized, controlled trial.

Brief Report: A Randomized Control Trial Assessing the Influence of a Telephone-based Intervention on Readmissions for Patients with Severe Mental Illness in a Developing Country

Whilst comprehensive post-discharge interventions have been successful in reducing readmissions in our setting, they are possibly not sustainable due to limited resources. We assessed the impact of a more cost-effective telephone-based intervention on readmissions in a developing country over 12 months. 100 patients with severe mental illness were randomized to facilitated care or treatment as usual. All were interviewed prior to discharge and after 12 months. Facilitated care consisted of structured telephonic interviews and motivational support to patients and families. At 12 months no significant differences in either readmissions (p = 0.10) or days in hospital (p = 0.44) could be demonstrated. Substance use was high (64%), particularly methamphetamine (44%) in both groups. The intervention did not have any impact on inpatient usage in our setting. Though this study was limited by its small sample size, the results indicated that affordable post-discharge services may not be comprehensive enough to reduce readmission rates and would have to be tailored to the distinct population of dual diagnosis patients identified in this study.

Discharge management strategies and post-discharge care interventions for depression - Systematic review and meta-analysis

BACKGROUND

Patients with depression require treatment continuity when discharged from inpatient care. Interventions aimed at optimizing transition into outpatient care may be effective in preventing symptom deterioration and readmission. We aimed to evaluate the effectiveness of care transition interventions for patients with depression after psychiatric hospitalization.

METHODS

Systematic review and random-effects meta-analysis of controlled trials. Primary outcomes were readmissions and symptoms of depression. The control condition was treatment as usual.

RESULTS

We included 16 publications reporting the results of 13 different studies. Studies were heterogeneous concerning patient selection and interventional approach. Effects on readmissions and depression symptoms were non-significant in meta-analysis of 8 studies/710 patients and 7 studies/592 patients, respectively. Overall risk ratio for readmission during follow-up was 0.65 (95% CI [0.42;1.01], p=0.06), standardized mean difference for depression symptoms was -0.09 (95% CI [-0.37;0.19], p=0.53). Subgroup analyses indicated no preference for a specific interventional strategy. Data point to considerable risk for selection and publication bias.

LIMITATIONS

Included studies are heterogeneous; subgroups are often small and may not attain the power to detect effects. Reasonable classification of interventions into groups of comparable approaches was a challenge and may be arbitrary in some cases.

CONCLUSIONS

This systematic review and meta-analysis could not identify any convincingly effective interventional transition approach for patients with depression after psychiatric hospitalization. Current evidence regarding discharge management for depression is limited, heterogeneous and potentially prone to bias. Interventions might be more appropriate for patients with other diagnoses than depression. Further high-quality randomized studies are required.

What is the Lived Experience of Being Discharged From a Psychiatric Inpatient Stay?

Psychiatric patients encounter many difficulties post-discharge reflected by quantitative data such as high suicide rates within the first 3 months. However, little is known about why discharge is so difficult. This article aimed to understand the lived experience of being discharged from a psychiatric unit. Eight participants were interviewed to explore their experiences of discharge. Interpretative phenomenological analysis was used to analyse data. Four superordinate themes emerged: leaving hospital; the outside world; the journey to health; and self-identity/beliefs. Clinical implications and suggestions for further research are discussed.

The role of perceived social support after psychiatric hospitalisation: Post hoc analysis of a randomised controlled trial testing the effectiveness of a transitional intervention

BACKGROUND

The association between social support, readmissions and psychopathology following discharge from psychiatric hospitals is not clear.

AIMS

To examine the prospective effects of perceived social support on rehospitalisation rates and psychopathology and to focus on the moderators of a transitional intervention.

METHOD

This post hoc analysis of a multisite randomised controlled trial included 151 patients with no more than three hospitalisations within the last 3 years, a Global Assessment of Functioning (GAF) score ≤60 and aged 18-64 years, assessed at two psychiatric hospitals from Zurich, Switzerland, between September 2011 and February 2014. Participants received either a transitional intervention aimed at improving social support during the transition from inpatient to outpatient care provided by a social worker or treatment as usual.

RESULTS

Lack of perceived social support at discharge significantly predicted subsequent rehospitalisation rates and increased psychopathological impairment across 12-month follow-up. Significant interaction effects between patient characteristics and the intervention on perceived social support comprised living at parent's home, having no children and being of younger age.

CONCLUSION

Perceived social support at discharge from inpatient care may reduce rehospitalisation rates and psychopathological impairment in the long term. A transitional intervention aimed at improving social support may negatively impact on the perceived social support in some patient groups.

Factors influencing patients' recovery and the efficacy of a psychosocial post-discharge intervention: post hoc analysis of a randomized controlled trial

PURPOSE

The aim of this post hoc analysis was to examine self-reported recovery following a post-discharge intervention and to focus on the moderators of this intervention programme.

METHODS

RCT using parallel group block randomisation, including 151 patients with ≤3 hospitalisations within the last 3 years, a GAF score ≤60, and aged 18-64 years, assessed at two psychiatric hospitals from Zurich, Switzerland, between September 2011 and February 2014. In the present study, the main outcome was the OQ-45 as assessed prior to discharge from the index hospitalisation and at 12-month follow-up. Participants received either the post-discharge intervention provided by a social worker or treatment as usual (TAU).

RESULTS

Patients in the intervention group showed substantially less recovery over the 12-month observation period than controls (d = 0.44). In the TAU group, 15.6 % remained clinically impaired at 12-month follow-up as opposed to 48.1 % in the intervention group (p = 0.001). Among participants in the intervention group, an interdisciplinary meeting of significant network members was associated with less recovery (d = 0.46). Involuntary index admission (d = 0.42) and high educational degree (d = 0.52) were significant moderators of the intervention. Both factors related to less recovery over time in the intervention group relative to TAU.

CONCLUSIONS

According to the OQ-45, this psychosocial post-discharge intervention revealed an unintended negative effect on self-reported recovery over time. Specifically, the meeting of significant network members related to a moderate deteriorating effect, suggesting that the involvement of some carers, relatives, or friends may cause harm to the patient. Considering with reservation pending replication, these findings could have important implications for brief interventions targeted at patients' social networks.

FUNDING

This study was supported by a private foundation.

TRIAL REGISTRATION

ISRCTN58280620.

[Concept and results of the German Research Network on Schizophrenia]

BACKGROUND

The German Research Network on Schizophrenia (GRNS) was funded by the Federal Ministry of Education and Research (BMBF) from 1999 to 2011. The aim was to obtain a better horizontal and vertical networking of German research and care facilities on schizophrenia, in order to investigate open research questions, to transfer the results into clinical practice and improve care and quality of life in patients with schizophrenia.

OBJECTIVES/METHODS

This paper describes the concept and operations of the GRNS as well as its results on the basis of selected research projects.

RESULTS

The GRNS comprised about 25 clinical trials of high practical relevance, which were closely interrelated regarding content, methodology and organization. The trials primarily served the development and evaluation of new and established diagnostic and therapeutic approaches, the assessment of the status quo of clinical care, as well as its improvements, together with the investigation of basic scientific questions. Many substantial results to highly relevant issues were obtained, which led or will lead to an improvement in mental health care.

CONCLUSIONS

Quantitative and qualitative evaluation parameters, such as scientific publications and obtaining additional grants, as well as promotion of young scientists, public relations activities, congress activities and the foundation of a European Schizophrenia Association, document the successful work of the network. Successful funding requests will allow us to continue cooperative schizophrenia research in Germany as initiated by the GRNS, without necessarily always binding these activities formally to the GRNS.

Linking Primary and Secondary Care after Psychiatric Hospitalization: Comparison between Transitional Case Management Setting and Routine Care for Common Mental Disorders

OBJECTIVES

To improve engagement with care and prevent psychiatric readmission, a transitional case management intervention has been established to link with primary and secondary care. The intervention begins during hospitalization and ends 1 month after discharge. The goal of this study was to assess the effectiveness of this short intervention in terms of the level of engagement with outpatient care and the rate of readmissions during 1 year after discharge.

METHODS

Individuals hospitalized with common mental disorders were randomly assigned to be discharged to routine follow-up by private psychiatrists or general practitioners with (n = 51) or without (n = 51) the addition of a transitional case management intervention. Main outcome measures were number of contacts with outpatient care and rate of readmission during 12 months after discharge.

RESULTS

Transitional case management patients reported more contacts with care service in the period between 1 and 3 months after discharge (p = 0.004). Later after discharge (3-12 months), no significant differences of number of contacts remained. The transitional case management intervention had no statistically significant beneficial impact on the rate of readmission (hazard ratio = 0.585, p = 0.114).

CONCLUSION

The focus on follow-up after discharge during hospitalization leads to an increased short-term rate of engagement with ambulatory care despite no differences between the two groups after 3 months of follow-up. This short transitional intervention did, however, not significantly reduce the rate of readmissions during the first year following discharge.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier NCT02258737.

The Post-Discharge Network Coordination Programme: A Randomized Controlled Trial to Evaluate the Efficacy of an Intervention Aimed at Reducing Rehospitalizations and Improving Mental Health

PURPOSE

To evaluate the efficacy of a post-discharge intervention for psychiatric inpatients aimed at preventing hospital readmissions and at improving patients' mental health and psychosocial functioning.

METHODS

Randomized controlled trial using parallel group block randomization including 151 patients with ≤3 hospitalizations within the last 3 years, a GAF score ≤60, and aged 18-64 years, assessed at two psychiatric hospitals from the canton of Zurich, Switzerland, between September 2011 and February 2014. Primary outcomes were rate and duration of rehospitalization; secondary outcomes were mental health and functioning. Outcome measures were assessed before discharge from the index hospitalization (t 0), 3 months after discharge when the intervention terminated (t 1), and 12 months after discharge (t 2). Participants received either a brief case management post-discharge intervention or treatment as usual.

RESULTS

In the short-term (i.e., t 0-t 1), no significant effect emerged in any outcome. In the long term (i.e., t 0-t 2), the two groups did not differ significantly with respect to the rate and duration of rehospitalization. Also, the intervention did not reduce psychiatric symptoms, did not improve social support, and did not improve quality of life. However, it did slightly increase assessor-rated general (d = 0.30) and social functioning (d = 0.42), although self-reports revealed a deteriorative effect on symptom remission (d = -0.44).

CONCLUSION

This psychosocial post-discharge intervention showed no efficacy in the primary outcome of rehospitalization. With respect to secondary outcomes, in the long term it might lead to slightly increased social functioning but revealed no significant effect on psychopathology, social support, and quality of life. By contrast, with respect to self-reported symptom remission, it was revealed to have a negative effect. In this high-resource catchment area with comprehensive community psychiatric and social services, the intervention thus cannot be recommended for implementation in routine care.

Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis

BACKGROUND

Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group.

METHODS

We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted.

RESULTS

We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89).

INTERPRETATION

We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).

A pilot randomized control trial: testing a transitional care model for acute psychiatric conditions

OBJECTIVE

People with multiple and persistent mental and physical health problems have high rates of transition failures when transferring from a hospital level of care to home. The transitional care model (TCM) is evidence-based and demonstrated to improve posthospital outcomes for elderly with physical health conditions, but it has not been studied in the population with serious mental illness.

METHOD

Using a randomized controlled design, 40 inpatients from two general hospital psychiatric units were recruited and randomly assigned to an intervention group (n = 20) that received the TCM intervention that was delivered by a psychiatric nurse practitioner for 90 days posthospitalization, or a control group (n = 20) that received usual care. Outcomes were as follows: service utilization, health-related quality of life, and continuity of care.

RESULTS

The intervention group showed higher medical and psychiatric rehospitalization than the control group (p = .054). Emergency room use was lower for intervention group but not statistically significant. Continuity of care with primary care appointments were significantly higher for the intervention group (p = .023). The intervention group's general health improved but was not statistically significant compared with controls.

CONCLUSIONS

A transitional care intervention is recommended; however, the model needs to be modified from a single nurse to a multidisciplinary team with expertise from a psychiatric nurse practitioner, a social worker, and a peer support specialist. A team approach can best manage the complex physical/mental health conditions and complicated social needs of the population with serious mental illness.

Network coordination following discharge from psychiatric inpatient treatment: a study protocol

BACKGROUND

Inadequate discharge planning following inpatient stays is a major issue in the provision of a high standard of care for patients who receive psychiatric treatment. Studies have shown that half of patients who had no pre-discharge contact with outpatient services do not keep their first outpatient appointment. Additionally, discharged patients who are not well linked to their outpatient care networks are at twice the risk of re-hospitalization. The aim of this study is to investigate if the Post-Discharge Network Coordination Program at ipw has a demonstrably significant impact on the frequency and duration of patient re-hospitalization. Subjects are randomly assigned to either the treatment group or to the control group. The treatment group participates in the Post-Discharge Network Coordination Program. The control group receives treatment as usual with no additional social support. Further outcome variables include: social support, change in psychiatric symptoms, quality of life, and independence in daily functioning.

METHODS/DESIGN

The study is conducted as a randomized controlled trial. Subjects are randomly assigned to either the control group or to the treatment group. Computer generated block randomization is used to assure both groups have the same number of subjects. Stratified block randomization is used for the psychiatric diagnosis of ICD-10, F1. Approximately 160 patients are recruited in two care units at Psychiatrie-Zentrum Hard Embrach and two care units at Klinik Schlosstal Winterthur.

DISCUSSION

The proposed post-discharge network coordination program intervenes during the critical post-discharge period. It focuses primarily on promoting the integration of the patients into their social networks, and additionally to coordinating outpatient care and addressing concerns of daily life.

TRIAL REGISTRATION ISRCTN

ISRCTN58280620.

Discharge planning in mental health care: an integrative review of the literature

AIMS AND OBJECTIVES

To identify the evidence base related to discharge planning in the context of acute and community mental healthcare service provision to ascertain the need for future research.

BACKGROUND

Discharge planning is an important activity when preparing consumers to transition from hospital to home. The efficiency of discharge planning for consumers living with a mental health issue can influence both the number of future readmissions to acute-care facilities and their quality of life at home.

DESIGN

An integrative review of the peer-reviewed literature.

METHOD

This review uses specific search terms and a 21-year time frame to search two key nursing databases CINAHL (Cinahl Information Systems, Glendale, CA, USA) and PSYCHINFO (American Psychological Association, Washington, DC, USA) for research reports investigating the substantive area of enquiry. Hand searches of reference lists and author searches were also conducted. Nineteen peer-reviewed journal articles met the inclusion criteria for this review.

RESULTS

Research findings about discharge planning for people living with a mental health issue identify the importance of communication between health professionals, consumers and their families to maximise the effectiveness of this process. The complexity of consumer's healthcare needs influences the discharge planning process and impacts on aftercare compliance and readmission rates. There is a limited amount of research findings relating to differences between health professionals and families' perceptions of the level of information required for effective discharge planning, and the appropriate level of involvement of individuals living with a mental health issue in their own discharge planning. Results from this integrative review will inform future research related to this topic.

CONCLUSION

Discharge planning for consumers living with a mental health issue involves many stakeholders who have different expectations regarding the type of information required and the necessary level of involvement of people living with a mental health issue in this process.

RELEVANCE TO CLINICAL PRACTICE

Comprehensive discharge planning can result in reduced readmissions to both acute and community mental health services. Understanding the impact of effective communication on the outcomes of discharge planning is an important step in promoting success.