Continuity of Care among People Experiencing Homelessness and Mental Illness: Does Community Follow-up Reduce Rehospitalization?

A non-randomised controlled trial of a community-based accommodation and psychosocial support programme for adults experiencing mental illness and homelessness

BACKGROUND

The transition out of inpatient mental health is a crucial time for adults experiencing concurrent mental illness and homelessness, yet evidence regarding effective support options is mixed. Choices is an intensive 3-month psychosocial outreach and crisis accommodation support programme for adults experiencing mental illness and homelessness, delivered by Baptcare in Tasmania, Australia. This study examined the effect of Choices on adults' psychosocial functioning, clinical symptomology and psychiatric readmissions in comparison to standard care only.

METHOD

Participants were adults aged 18-64 years experiencing mental illness and homelessness, recruited upon discharge from a psychiatric admission. Intervention participants (n = 124) received the Choices programme. Control participants (n = 122) received standard care, clinical assessment and treatment from hospital-based Mental Health Services. Outcomes were psychosocial functioning (primary), clinical symptomology, hospital readmission rate and readmission length of stay. Outcomes were assessed at programme commencement and closure (3 months) and 3 months post-closure (intervention group only). Analysis of covariance was used to analyse differences between groups at closure, while controlling for baseline differences.

RESULTS

Intervention participants had significantly improved social functioning (encompassing living conditions, social relationships, self-esteem/confidence), overall psychosocial functioning, symptoms of depression and anxiety and shorter hospital readmission length of stay in comparison to the control group. Intervention participants experienced further improvements in social and overall psychosocial functioning 3 months post-closure.

CONCLUSION

The Choices programme is effective in enhancing the psychosocial functioning of adults experiencing concurrent mental illness and homelessness. These findings support the ongoing delivery of this combined accommodation and wrap-around psychosocial model of intensive support.

Association of homelessness and psychiatric hospital readmission-a retrospective cohort study 2016-2020

BACKGROUND

A large proportion of adult psychiatric inpatients experience homelessness and are often discharged to unstable accommodation or the street. It is unclear whether homelessness impacts psychiatric hospital readmission. Our primary objective was to examine the association between homelessness and risk for 30-day and 90-day readmission following discharge from a psychiatric unit at a single urban hospital.

METHODS

A retrospective cohort study involving health administrative data among individuals (n = 3907) in Vancouver, Canada with an acute psychiatric admission between January 2016 and December 2020. Participants were followed from the date of index admission until censoring (December 30, 2020). Homelessness was measured at index admission and treated as a time-varying exposure. Adjusted Hazard Ratios (aHRs) of acute readmission (30-day and 90-day) for psychiatric and substance use disorders were estimated using multivariable Cox proportional hazards regression.

RESULTS

The cohort comprised 3907 individuals who were predominantly male (61.89%) with a severe mental illness (70.92%), substance use disorder (20.45%) and mean age of 40.66 (SD, 14.33). A total of 686 (17.56%) individuals were homeless at their index hospitalization averaging 19.13 (21.53) days in hospital. After adjusting for covariates, patients experiencing homelessness had a 2.04 (1.65, 2.51) increased rate of 30-day readmission and 1.65 (1.24, 2.19) increased rate of 90-day readmission during the observation period.

CONCLUSIONS

Homelessness was significantly associated with increased 30-day and 90-day readmission rates in a large comprehensive sample of adults with mental illness and substance use disorders. Interventions to reduce homelessness are urgently needed.

QUESTION

Is homelessness associated with risk for 30-day and 90-day psychiatric hospital readmission?

FINDINGS

In this retrospective cohort study of 3907 individuals, homelessness at discharge was associated with increased 30-day and 90-day psychiatric readmission.

MEANING

Housing status is an important risk factor for hospital readmission. High-quality interventions focused on housing supports have the potential to reduce psychiatric readmission.

Risk of psychiatric readmission in the homeless population: A 10-year follow-up study

Homelessness continues to be a major social and clinical problem. The homeless population has a higher burden of disease that includes psychiatric disorders. In addition, they have a lower use of ambulatory health services and a higher use of acute care. Few investigations analyze the use of services of this population group in the long term. We analyzed the risk of psychiatric readmission of homeless individuals through survival analysis. All admissions to a mental health hospitalization unit in the city of Malaga, Spain, from 1999 to 2005, have been analyzed. Three analyses were carried out: two intermediate analyses at 30 days and 1 year after starting follow-up; and one final analysis at 10 years. In all cases, the event was readmission to the hospitalization unit. The adjusted Hazard Ratio at 30 days, 1-year, and 10-year follow-ups were 1.387 (p = 0.027), 1.015 (p = 0.890), and 0.826 (p = 0.043), respectively. We have found an increased risk of readmission for the homeless population at 30 days and a decreased risk of readmission at 10 years. We hypothesize that this lower risk of long-term readmission may be due to the high mobility of the homeless population, its low degree of adherence to long-term mental health services, and its high mortality rate. We suggest that time-critical intervention programs in the short term could decrease the high rate of early readmission of the homeless population, and long-term interventions could link them with services and avoid its dispersion and abandonment.

Lack of continuity of care experienced by people diagnosed with schizophrenia in South Korea

People diagnosed with schizophrenia (PDS) will find seamlessly coordinated services and care in their communities if they are delivered with a high level of continuity of care (COC). Most studies of COC were conducted in Western countries that initiated deinstitutionalisation several decades ago. Limited studies highlight experiences of COC among PDS who live in societies still heavily relying on institutionalised care, such as prolonged hospitalisation, like South Korea where PDS stay in psychiatric hospitals over 100 days on average. This qualitative study explored COC that PDS experienced in South Korea. We focused on cross-boundary COC, which refers to service coordination at a given moment, and longitudinal COC, which refers to care over a period of time. Twenty-one PDS completed in-depth interviews from June to August 2017. Fifteen participants were male (71.4%), and ages ranged from 26 to 71. We used grounded theory techniques for data analysis, including initial open coding, in vivo coding, constant comparison and axial coding. Findings include that PDS experienced poor longitudinal COC when discharge planning during hospitalisation was absent, which undermined their ability to live independently. Poor employment support effectively undermined recovery even if PDS worked hard to attain economic self-sufficiency. As for cross-boundary COC, poor communication between psychiatrists and providers offering psychiatric rehabilitation services was a barrier. PDS in general had difficulties locating needed psychiatric rehabilitation services in the community. The lack of COC appeared to arise from particular sociocultural contexts, including poor self-determination in consumer-provider relationships, families' lack of knowledge and support, and discrimination and prejudice. Despite experiences with discrimination, no participants appeared to have internalised messages that they are 'less than' those without mental illnesses. Findings highlight the significance of multi-pronged approaches to increase COC, which can effectively link PDS, families, psychiatrists and psychiatric rehabilitation service providers.

Characterization of multilevel influences of mental health care transitions: a comparative case study analysis

PURPOSE

Mental health care transitions are increasingly prioritized given their potential to optimize care delivery and patient outcomes, especially those focused on the transition from inpatient to outpatient mental health care. However, limited efforts to date characterize such mental health transition practices, especially those spanning multiple service setting contexts. Examination of key influences of inpatient to outpatient mental health care transitions across care contexts is needed to inform ongoing and future efforts to improve mental health care transitions. The current work aims to characterize multilevel influences of mental health care transitions across three United States-based mental health system contexts.

METHODS

A comparative multiple case study design was used to characterize transition practices within the literature examining children's, non-VA adult, and VA adult service contexts. Andersen's (1995) Behavioral Health Service Use Model was applied to identify and characterize relevant distinct and common domains of focus in care transitions across systems.

RESULTS

Several key influences to mental health care transitions were identified spanning the environmental, individual, and health behavior domains, including: community capacity or availability, cross-system or agency collaboration, provider training and experience related to mental health care transitions, client care experience and expectations, and client clinical characteristics or complexity.

CONCLUSIONS

Synthesis illustrated several common factors across system contexts as well as unique factors for further consideration. Our findings inform key considerations and recommendations for ongoing and future efforts aiming to plan, expand, and better support mental health care transitions. These include timely information sharing, enhanced care coordination and cross setting and provider communication, continued provider/client education, and appropriate tailoring of services to improve mental health care transitions.

Traumatic brain injury in the homeless: health, injury mechanisms, and hospital course

Primary ObjectiveEstablished literature demonstrates that homeless individuals experience both greater disease burden and risk of experiencing traumatic brain injury (TBI) than the general population. Similarly, shared risk factors for both homelessness and/or TBI may exacerbate the risk of repetitive neurotrauma within homeless populations.Research DesignWe leveraged a state-wide trauma registry, the Pennsylvania Trauma Outcome Study (PTOS), to characterize 609 patients discharged to homeless (58% TBI, 42% orthopedic injury (OI)) in comparison to 609 randomly sampled adult patients discharged to home.Methods and ProceduresWe implemented Chi-square tests to examine preexisting health conditions (PECs), hospital course, and injury mechanisms for both patient groups.Main Outcomes and ResultsHomelessness affects a greater proportion of nonwhite patients, and homeless patients present for care with increased frequencies of psychiatric and substance use PECs, and alcohol-positive TBI. Furthermore, assault impacts a larger proportion of homeless patients, and the window for overnight assault risk resulting in TBI is extended for these patients compared to patients discharged to home.ConclusionGiven the shifting conceptualization of TBI as a chronic condition, identifying homeless patients on admission to trauma centers, rather than retrospectively at discharge, can enhance understanding of the challenges facing the homeless as they age with both a complex neurotrauma history and multimorbidity.

Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness

BACKGROUND

People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients.

OBJECTIVE

To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness.

DESIGN

This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals.

PARTICIPANTS

Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission.

MAIN MEASURES

Unplanned all-cause readmission to the study hospital within 90 days of discharge.

KEY RESULTS

Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23).

CONCLUSION

Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.

Measurement of unnecessary psychiatric readmissions in the context of care transition interventions: a scoping review

OBJECTIVE

The objective of this study was to examine how published studies of inpatient to outpatient mental healthcare transition processes have approached measuring unnecessary psychiatric readmissions.

DESIGN

Scoping review using Levac et al's enhancement to Arksey and O'Malley's framework for conducting scoping reviews.

DATA SOURCES

Medline (Ovid), Embase (Ovid), PsycINFO, CINAHL, Cochrane and ISI Web of Science article databases were searched from 1 January 2009 through 28 February 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies that (1) are about care transition processes associated with unnecessary psychiatric readmissions and (2) specify use of at least one readmission time interval (ie, the time period since previous discharge from inpatient care, within which a hospitalisation can be considered a readmission).

DATA EXTRACTION AND SYNTHESIS

We assessed review findings through tabular and content analyses of the data extracted from included articles.

RESULTS

Our database search yielded 3478 unique articles, 67 of which were included in our scoping review. The included articles varied widely in their reported readmission time intervals used. They provided limited details regarding which readmissions they considered unnecessary and which risks they accounted for in their measurement. There were no perceptible trends in associations between the variation in these findings and the included studies' characteristics (eg, target population, type of care transition intervention).

CONCLUSIONS

The limited specification with which studies report their approach to unnecessary psychiatric readmissions measurement is a noteworthy gap identified by this scoping review, and one that can hinder both the replicability of conducted studies and adaptations of study methods by future investigations. Recommendations stemming from this review include (1) establishing a framework for reporting the measurement approach, (2) devising enhanced guidelines regarding which approaches to use in which circumstances and (3) examining how sensitive research findings are to the choice of the approach.

Outcomes of a Citywide Campaign to Reduce Medicaid Hospital Readmissions With Connection to Primary Care Within 7 Days of Hospital Discharge

IMPORTANCE

Previous research suggests the important role of timely primary care follow-up in reducing hospital readmissions, although effectiveness varies by program design and patients' readmission risk level.

OBJECTIVE

To evaluate the outcomes of the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of hospital readmissions among Medicaid patients 18 years or older hospitalized from January 1, 2014, to April 30, 2016, in Camden, New Jersey. To assess each patient's hospital use before and after hospital discharge, all-payer claims data from 4 health care systems were linked to insurers' lists of patients assigned to Camden-based primary care practices. A total of 1531 records were categorized by timing of a primary care appointment after discharge. Discharges followed by a primary care appointment within 7 days (treatment group) were matched by propensity scores to those with less timely or no primary care follow-up (nontreatment pool).

INTERVENTIONS

Targeted patient enrollment during hospital admission, primary care practice engagement, patient incentives to overcome barriers to keeping an appointment, and reimbursements to practices for prioritizing patients recently discharged from the hospital.

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of hospital discharges followed by a readmission within 30 days. The secondary outcome was the number of hospital discharges followed by a readmission within 90 days.

RESULTS

There were 2580 hospitalizations of patients 18 years and older included on the patient lists from January 1, 2014, to April 30, 2016. Of these, 1531 records categorized by timing of a primary care appointment after discharge were studied. The treatment group consisted of 450 discharged patients (mean [SD] age, 48.7 [14.7] years; 289 [64.2%] female; 203 [45.1%] black, non-Hispanic). The nontreatment pool consisted of 1081 discharged patients (mean [SD] age, 48.1 [14.9] years; 599 [55.4%] female; 526 [48.7%] black, non-Hispanic). Among this cohort, the number of discharges followed by any readmission was lower for patients with a primary care visit within 7 days of hospital discharge than for their matched referents at 30 days (57 of 450 [12.7%] vs 78.8 of 450 [17.5%]; P = .03) and 90 days (126 of 450 [28.0%] vs 174 of 450 [38.7%]; P = .002) after discharge.

CONCLUSIONS AND RELEVANCE

Facilitated receipt of primary care follow-up within 7 days of hospital discharge was associated with fewer Medicaid readmissions. The findings illuminate the importance of reducing barriers that patients and providers face during care transitions.