Unmet Opportunity: Intensive Care Transition Intervention for Individuals With Serious Medical-Psychiatric Illnesses

People with a serious mental illness, such as recurrent major depressive disorder, bipolar disorder, or a schizophrenia spectrum disorder, have substantially shortened life expectancies (1). This excess mortality is primarily due to chronic medical conditions associated with highly prevalent risk factors among these patients, including nicotine and/or tobacco use, cardiometabolic conditions, and a sedentary lifestyle (2). Difficulties accessing and adhering to recommended medical care also increase risk of adverse outcomes and premature mortality among people with serious mental illness and chronic medical conditions, hereafter called serious medical-psychiatric illnesses (SMPIs).

SMPIs are among the most expensive conditions to manage, and much of the health care costs for individuals with these illnesses are attributable to management of medical rather than psychiatric conditions (3). Although data regarding follow-up care of people with SMPIs after discharge from medical-surgical units are not available, one could assume that their follow-up rates are low, given the combined burden of medical and psychiatric illness. A critical need exists to develop effective care transition interventions for adults with SMPIs to prevent gaps in medical and mental health care during the period immediately after inpatient hospital care.

Intensive care management interventions have been developed for elderly persons who have chronic medical or psychosocial problems requiring moderate or highly complex medical decision making (4, 5). These time-limited services, which include low-intensity therapy and training to support self- and illness-management skills such as medication adherence, have been shown to improve rates of successful transition from hospital to community care (4, 5). Despite their demonstrated effectiveness, these interventions are unlikely to meet the more complex psychosocial and medical needs of individuals with SMPIs. These individuals have unique care management needs related to severe functional deficits in domains including self-care, social skills, and independent living; cognitive deficits, including reality distortions, impulsivity, and impaired problem-solving; and the perceived stigma and inadequate training of general health care professionals related to these patients’ needs. People with SMPIs benefit from face-to-face intensive care management. They need care management that is persistent and conducted in person; is delivered by care managers familiar with the local behavioral and primary care health systems (these individuals often engage with health care primarily through connections with psychiatric providers, which need to be leveraged to promote adherence with medical care); is delivered by care managers who can use motivational interviewing, shared decision making, deescalation, and reality testing techniques; includes advocacy on behalf of the individual when indicated; and mobilizes family and other key collateral persons to provide similar support.

Some evidence-based interventions can be adapted to meet the needs of individuals who have SMPIs. Critical time intervention (CTI) is a time-limited approach that mobilizes support during transition periods for people with mental illness at high risk. It is characterized by frequent face-to-face visits by a trained care manager beginning before discharge from the hospital and maintained throughout a period of transition and engagement with community services, provision of practical and emotional support, and the building of sustainable linkages to community-based providers, services, family, and friends. CTI has been successfully applied to populations including adults with mental illness, homeless individuals with mental illness, and individuals transitioning from prison to the community (6–8). CTI services improve connections with community-based care among individuals who have high health and social service costs. In one study, brief (3-month) CTI was associated with a significantly lower risk of hospital readmission within 30 days of hospital discharge (28% versus 47%) (8).

Given its demonstrated effectiveness in other high-risk populations, CTI should be adapted as an approach to improve transitions from inpatient to outpatient care for individuals with SMPIs. Our group is pilot testing a modified brief CTI intervention with funding through the National Institute of Mental Health (NIMH) Optimizing and Personalizing Interventions for People With Schizophrenia Across the Lifespan (OPAL) Center at the New York State Psychiatric Institute. The OPAL Center was created in response to a NIMH funding opportunity announcement for ALACRITY (Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults With Mental Illness) research centers, with the primary goal of accelerating the development and implementation of effective, individualized treatments for patients with schizophrenia in clinical settings.