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

Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis

Importance

Discharge from the hospital to the community has been associated with serious patient risks and excess service costs.

Objective

To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community.

Data Sources

CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022.

Study Selection

Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified.

Data Extraction and Synthesis

At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.

Main Outcomes and Measures

The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake.

Results

Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits.

Conclusions and Relevance

These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.

Nurse-Led Physical Health Interventions for People with Mental Illness: A Scoping Review of International Literature

People with mental illness have a higher prevalence of co-occurring physical health conditions and poor health behaviors, leading a mortality gap of up to 16 years, compared with the general population. Nurses working in mental health settings play an important role in addressing factors influencing sub-optimal physical health. Therefore, this scoping review aimed to identify nurse-led physical health interventions and align interventions to eight recognized physical healthcare priority areas (i.e. Equally Well in Victoria Framework). A systematic search strategy was used to identify relevant literature. Data extraction included alignment to the Equally Well priority areas, research design, and indication of co-design (meaningful and collaborative involvement of consumers and significant others) and recovery-oriented practice (focusing on needs and goals of a consumer's recovery journey). All included papers (n = 74) were aligned to at least one of eight Equally Well priority areas. Papers were predominately quantitative (n = 64, 86%), with the remainder mixed methods (n = 9, 9%) or qualitative (n = 4, 5%). Most papers were aligned to improving metabolic health and support to quit smoking. One study focused on nurse-led intervention designed to reduce falls. Recovery-oriented practice was evident in six papers. No paper described evidence of co-design. A research gap was identified for nurse-led intervention to reduce falls and improve dental/oral care. Relative to mental healthcare policy, there is a need for future nurse-led physical health research to be co-designed and include recovery-oriented practice. Evaluation and description of future nurse-led physical interventions should seek to report perspectives of key stakeholders as these remain relatively unknown.

Randomized controlled trials of mental health nurse-delivered interventions: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Well conducted randomized controlled trials provide the highest level of evidence of effectiveness of healthcare interventions, including those delivered by mental health nurses. Trials have been conducted over the years but there has not been a comprehensive review since 2005, and never one including studies conducted outside the UK. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper provides a comprehensive overview of results from randomized controlled trials of mental health nurse-delivered interventions conducted in the UK, Ireland, US, Australia, New Zealand, or Canada and reported 2005 to 2020. It highlights that the trial evidence is limited and offers only partial evidence for interventions that are central to mental health nursing practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Much mental health nursing practice is not supported by the highest level trial evidence. Mental health nurses need to carefully select evidence on which to base their practice both from the mental health nursing literature and beyond. Mental health nurses and other stakeholders should demand greater investment in trials to strengthen the evidence base.

ABSTRACT

INTRODUCTION: Nurses are the largest professional disciplinary group working in mental health services and have been involved in numerous trials of nursing-specific and multidisciplinary interventions. Systematic appraisal of relevant research findings is rare.

AIM

To review trials from the core Anglosphere (UK, US, Canada, Ireland, Australia, New Zealand) published from 2005 to 2020.

METHOD

A systematic review reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Comprehensive electronic database searches were conducted. Eligible studies were randomized controlled trials of mental health nurse-delivered interventions conducted in relevant countries. The risk of bias was independently assessed. Synthesis involved integration of descriptive statistics of standardized metrics and study bias.

RESULTS

Outcomes from 348 between-group comparisons were extracted from K = 51 studies (N = 11,266 participants), Standardized effect sizes for 68 (39 very small/small, 29 moderate/large) statistically significant outcomes from 30 studies were calculable. All moderate/large effect sizes were at risk of bias.

DISCUSSION

Trial evidence of effective mental health nurse-delivered interventions is limited. Many studies produced few or no measurable benefits; none demonstrated improvements related to personal recovery.

IMPLICATIONS FOR PRACTICE

Mental health nurses should look beyond gold standard RCT evidence, and to evidence-based interventions that have not been trialled with mental health nurse delivery.

Psychiatric Medication Changes Associated With Increased Rate of Medical Readmissions in Patients With Serious Mental Illness

ABSTRACT

To identify the impact of postdischarge psychiatric medication changes on general medical readmissions among patients with serious mental illness (SMI; bipolar disorder, major depressive disorder, and schizophrenia), claims from a 5% national sample of Medicare fee-for-service (FFS) beneficiaries hospitalized between 2013 and 2016 were studied. A total of 165,490 Medicare FFS beneficiaries with SMI 18 years or older with at least 1 year of continuous Medicare enrollment were identified. Within 30 days of discharge from index admission, 47.4% experienced a psychiatric medication change-including 75,892 beneficiaries experiencing a deletion and 55,713 experiencing an addition. After adjusting for potential confounders, those with a medication change experienced an 10% increase in the odds of 30-day readmission (odds ratio, 1.10; SE, 0.019; p < 0.001). Comorbid drug use disorder was also associated with an increased odds of readmission after controlling for other covariates. These findings suggest important factors that clinicians should be aware of when discharging patients with SMI.

Transitional Care Models for High-Need, High-Cost Adults in the United States: A Scoping Review and Gap Analysis

Purpose of Study:

This scoping review explored research literature on the integration and coordination of services for high-need, high-cost (HNHC) patients in an attempt to answer the following questions: What models of transitional care are utilized to manage HNHC patients in the United States ? and How effective are they in reducing low-value utilization and in improving continuity ?

Primary Practice Settings:

U.S. urban, suburban, and rural health care sites within primary care, veterans’ services, behavioral health, and palliative care.

Methodology and Sample:

Utilizing the Joanna Briggs Institute and PRISMA guidelines for scoping reviews, a stepwise method was applied to search multiple databases for peer-reviewed published research on transitional care models serving HNHC adult patients in the United States from 2008 to 2018. All eligible studies were included regardless of quality rating. Exclusions were foreign models, studies published prior to 2008, review articles, care reports, and studies with participants younger than 18 years. The search returned 1,088 studies, of which 19 were included.

Results:

Four studies were randomized controlled trials and other designs included case reports and observational, quasi-experimental, cohort, and descriptive studies. Studies focused on Medicaid, Medicare, dual-eligible patients, veterans, and the uninsured or underinsured. High-need, high-cost patients were identified on the basis of prior utilization patterns of inpatient and emergency department visits, high cost, multiple chronic medical diagnoses, or a combination of these factors. Tools used to identify these patients included the hierarchical condition category predictive model, the Elder Risk Assessment, and the 4-year prognostic index score. The majority of studies combined characteristics of multiple case management models with varying levels of impact.

Implications for Case Management Practice:

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.

Healthcare Professionals' and Users' Experiences of Intersectoral Care between Hospital and Community Mental Healthcare

This paper explores healthcare professionals’ and users’ experience of coherent intersectoral care between hospital mental healthcare and community mental healthcare. A total of 20 healthcare professionals, primarily nurses, and 14 users with a range of mental illnesses participated in nine focus group interviews (FGIs). Participants were encouraged in the FGIs to reflect upon their experience of coherency in intersectoral care. The analysis of FGIs was informed by a phenomenological-hermeneutic approach in a research group from 2016–2019. The Consolidated Criteria for Reporting Qualitative Research checklist was used as a guideline to ensure complete and accurate reporting of the study. The analysis led to the generation of several themes from a professional perspective and from a user perspective, addressed barriers to coherent intersectoral care. The healthcare professionals experienced barriers such as a lack of common language and knowledge of partners. The users did not feel involved and lacked coherence in their recovery processes and, as such, intersectoral care was often experienced as being lost in a maze.

Nursing Advocacy and Long Acting Injectables to Reduce High Readmission Rates: Quality Initiative

INTRODUCTION: Nonadherence to medications for schizophrenia relates to frequent readmissions. Long-acting injectable (LAI) medications are shown to increase adherence and reduce admissions. AIMS: (1) Identify frequent readmissions to psychiatry. (2) Improve nursing advocacy for patients appropriate for LAIs through in-service. METHODS: Chart audits were employed for data collection. Academic detailing and dashboards were used for voluntary nursing education. The chart audit spanned 90 days pre and post in-service. All admissions to psychiatry were screened; patients with readmissions under 30 days (with the same admitting diagnosis), a schizophrenia spectrum diagnosis, and nonadherent with oral antipsychotics were included. Results: Forty-four patients met criteria and amassed 49 frequent readmissions. For inclusion criteria, the admission rate decreased by 53% and LAI prescriptions increased by 9%. Three patients from the first audit group and one from the second were initiated on LAIs. CONCLUSIONS: Attitudes toward LAIs may be improving based on RN advocacy and collaboration.

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.

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.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.

OBJECTIVES

To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.

MAIN RESULTS

The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).

AUTHORS' CONCLUSIONS

Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.

Examining the impact of comorbid serious mental illness on rehospitalization among medical and surgical inpatients

OBJECTIVE

Multiple barriers to quality health care may affect the outcomes of postacute treatment for individuals with serious mental illness (SMI). This study examined rehospitalization for medical and surgical inpatients with and without a comorbid diagnosis of SMI which included psychotic disorders, bipolar disorder and major depression.

METHODS

We examined hospital discharge records for medical and surgical inpatients from a large urban health system. Descriptive statistics and logistic regression models compared 7-, 30-, 60-, 90- and 180-day rehospitalization among medical and surgical inpatients with SMI (n=3221) and without an SMI diagnosis (n=70,858).

RESULTS

Within 6 months following discharge, hospitalized medical patients without an SMI diagnosis (34.3%) and with an SMI diagnosis (43.4%) were rehospitalized (P<.001), while surgical patients without an SMI diagnosis (20.3%) and with an SMI diagnosis (30.0%) were rehospitalized (P<.001). Odds of rehospitalization among medical patients were 1.5 to 2.4 times higher for those with an SMI diagnosis compared to those without an SMI diagnosis (P<.001).

CONCLUSIONS

Medical patients with a comorbid psychotic or major mood disorder diagnosis have an increased likelihood of a medical rehospitalization as compared to those without a comorbid SMI diagnosis. These findings support prior literature and suggest the importance of identifying targeted interventions aimed at lowering the likelihood of rehospitalization among inpatients with a comorbid SMI diagnosis.