Bridging Transitions of Care From Hospital to Community on the Foundation of Integrated and Collaborative Care
We build too many walls and not enough bridges.—attributed to Joseph Fort Newton (1)If you are good at building bridges, you will never fall into the abyss!—Mehmet Murat Ildan (2)
The transition of care (TOC) from hospital to community services is critical for persons with mental illness, whether they are being discharged from a medical unit or from a psychiatric hospital. Bridging the gap between the inpatient and outpatient settings is essential to support safety, ensure quality of care, decrease costs, and provide a positive experience for the patient and his or her family. However, hospital discharges are complex processes involving multiple persons, multiple steps, and multiple tasks across multiple organizations, thereby making TOC prone to problems for which single, simple solutions have yet to emerge. Strategies to support successful TOC bridging can be accomplished through a multitiered approach involving integration and collaboration. The Joint Commission has recognized that TOC requires collaboration across the entire care continuum (3). In this commentary, we focus on the transition from the inpatient setting to the community for the person in need of psychiatric services.
1.
The estimated readmission rate within one year of hospital discharge for psychiatric patients is approximately
A.
10%−20%
B.
30%−40%
C.
40%−50%
D.
70%−80%
Challenges in TOC can result in relapse and readmission. Jencks et al. studied rehospitalizations among patients in the Medicare fee-for-service program and found 30-day readmission rates of nearly 20%; of those who were readmitted, the second most frequent medical condition at discharge was psychosis (4). They further noted that the Medicare cost for those readmissions in 2004 reached $17.4 billion. With that financial burden being almost one-fifth of the total budget for hospital payments (4), the Centers for Medicare & Medicaid Services was motivated to implement the Readmissions Reduction Program in 2012 (5).
An Agency for Healthcare Research and Quality statistical brief (6) noted that the top two conditions with the most all-cause 30-day readmissions for Medicaid patients (18–64 years old) were psychiatric illnesses: mood disorders and schizophrenia and other psychotic disorders. In addition, alcohol- and substance-related disorders, when taken together, ranked third, higher than diabetes, complications of pregnancy, congestive heart failure, and septicemia.
A few individuals in the health care system consume a large share of health care resources. This cohort is identified as superutilizers. Strategies focusing on superutilizers target better TOC as a means of meeting the needs of these patients.
Are the following statements true or false?
2.
Mental health and substance use disorders were among the top ten principal diagnoses for superutilizers ages 1 to 64 years, regardless of payer.
3.
Although superutilizers represent 10% of the population, they account for one-third of health care expenditures.
4.
A three-month cohort of admissions to an acute psychiatric inpatient unit was studied and revealed that of the people hospitalized, one-third had been admitted to the hospital more than once.
As a component of the Robert Wood Johnson Foundation’s Aligning Forces for Quality Project, quality improvement collaborations are operational at six organizations to develop, implement, and study effective models to serve superutilizers outside emergency rooms (7). These integrated models include access not only to mental health clinicians and services but also to TOC bridging solutions.
Not all postdischarge relapse and TOC failures result in readmission. Further, relapse involves not only financial costs but also costs associated with disability. Relapse of mental illness is associated with homelessness (8), suicide (9), and violence (10). Relapse of mental illness can also result in incarceration (11).
Strategies to improve TOC have been developed both proactively and reactively.
5.
Access to and scheduling of a postdischarge appointment to occur within seven days of discharge is a widely accepted indicator of the quality of care. The State of Health Care Quality assessment in 2011 for the United States showed what proportion of patients being connected with outpatient care within seven days of discharge after psychiatric hospitalization?
A.
About 90%
B.
75%
C.
50% or less
D.
10%
Attention to TOC has been driven not only by cost but also by legal forces, including lawsuits. In New York, a class action lawsuit, Koskinas v. Cuomo, targeted TOC for improved coordination of care and provision of thorough discharge planning, including outpatient treatment. Among the requirements were that the first outpatient appointment needed to be scheduled to occur within seven days of discharge and housing needed to be arranged (12). These practices are standardized “regardless of whether the outpatient provider is connected to the hospital system or is located outside the city or state” (13). Humensky et al. (13) demonstrated success with a follow-up attendance rate at the initial appointment of 84%.
Changes in clinical safety practices have also occurred as reactions to tragedies like the following:
On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff. Plaintiffs, Tatiana’s parents, allege that two months earlier Poddar confided his intention to kill Tatiana to Dr. Lawrence Moore, a psychologist employed by the Cowell Memorial Hospital at the University of California at Berkeley. They allege that on Moore’s request, the campus police briefly detained Poddar, but released him when he appeared rational. They further claim that Dr. Harvey Powelson, Moore’s superior, then directed that no further action be taken to detain Poddar. No one warned plaintiffs of Tatiana’s peril (14).
This case has shaped TOC for the past four decades, with the resulting Tarasoff rules imposing a duty to warn and a duty to protect on therapists who perceive their patients posing credible threats to another person’s safety.
On April 16, 2007, on the campus of Virginia Tech in Blacksburg, Virginia, a student, Seung-Hui Cho, shot and killed 32 people, wounded 17, and killed himself. Sixteen months prior, Cho had been admitted to a psychiatric hospital on a temporary detention order as “an imminent danger to self or others.” He had an overnight stay and was committed to outpatient treatment. Failures in TOC for Cho occurred and likely played a part in the ensuing Virginia Tech tragedy. The governor of Virginia ordered a panel to study the events and make recommendations (15). Many of the key findings revealed poor integration and poor collaboration, including across TOC. For example, the inpatient psychiatrist who evaluated Cho did not contact the outpatient clinician. Also, handoff communication did not occur between the hospital and the university counseling center. Although a discharge summary was immediately dictated and transcribed, the university counseling center claimed that only a physical examination report was received, and that arrived a month after Cho’s discharge. Information was not shared sufficiently among administrative, academic, and public safety entities at the university. In addition, during the hospitalization, the psychiatrist did not obtain collateral information to assess risk, which was due in part to the insufficient time for evaluation and an overinterpretation of the HIPAA rules during an emergency, which kept the psychiatrist from contacting the family. These findings and other recommendations from the panel resulted not only in a transformation of mental health services in colleges across the country but also in significant changes in the mental health system for the Commonwealth of Virginia, including improvements in communication, collaboration, and integration of services, which, in turn, improved TOC.
Communication in a culture of collaboration, integration, and coordination of services is critical for patient safety.
6.
What percentage of serious medical errors involve miscommunication during the handoff between medical providers?
A.
20%
B.
32%
C.
65%
D.
80%
In addition, breakdowns in TOC can result in disconnection from employment, education, and family; marginalization of the patient into a passive or dependent role; duplication of services; an increase in medical errors; and medication errors (16).
7.
What are the top three causes of ineffective TOC?
A.
Accountability breakdowns
B.
Inadequate staff orientation, supervision, staffing levels, or skill mix
C.
Patient education breakdowns
D.
Communication breakdowns
E.
Human factors, such as lapses and cognitive bias
According to The Joint Commission (3), communication breakdowns are one of the top causes of clinicians’ not effectively communicating with each other, the patient, the family, and other caregivers. Underlying factors can be inadequate time, organizational culture, lack of standardized procedures, and even differing expectations between the persons on both sides of the TOC bridge. Failures in patient education can occur with poor medication reconciliation, conflicting information being provided to patients and family members, or even a lack of provision of patient education. Accountability breakdowns also occur in systems where there is no psychiatrist or clinician to take responsibility for coordinating the patient’s health care. Failure at the accountability level can be magnified for patients with complex psychiatric, medical, and social needs. Collaboration and integration are the structural underpinnings for solutions.
Several best practice models exist to improve patient outcomes across TOCs: the Agency for Healthcare Research and Quality’s Project RED (Re-Engineered Discharge training program [17]), the University of Pennsylvania School of Nursing’s Transitional Care Model (18), the Society of Hospital Medicine’s Project BOOST (Better Outcomes by Optimizing Safe Transitions) Mentored Implementation Program (19), Eric Coleman’s Care Transitions Program (20), Johns Hopkins’ Guided Care (21), Indiana University’s Geriatric Resources for Assessment and Care of Elders (22), The Bridge Model (23) in Illinois, and The Joint Commission’s Transitions of Care Portal with the Targeted Solutions Tool for handoff communications and other resources (24). Using the metaphor of a bridge for TOC, we note that three major structural divisions help to organize the similar features that these programs provide.
First, the foundation is the portion of the bridge that transfers loads to the bearing strata and supports all the structures above it. The foundation for TOC includes private and public payers, government agencies, policy makers, accreditation agencies, and federal and state laws. All of these elements of the foundation should support TOC and not hinder its stability.
Second, the substructure is the part of the bridge that supports the superstructure, the portion of the bridge that transfers loads. Support should include elements that allow clinicians to perform their jobs more easily, efficiently, and effectively as well as provide patients with a safe and successful journey.
Third, the TOC superstructure is the part of the bridge that the clinicians, patients, and family members navigate to get across the abyss from the inpatient to the outpatient world. The superstructure supports traffic load. Table 1 summarizes the key bridging components from the various TOC models with commentary regarding adaptation to psychiatric services.
8.
Coleman’s care transitions intervention demonstrated that an integrated care model can have what effects on TOC?
A.
Lower rehospitalization rates at slightly lower cost
B.
Lower rehospitalization rates at slightly higher cost
C.
Higher rehospitalization rates at slightly higher cost
D.
Lower rehospitalization rates at neutral cost
| Bridge Component | Program | Description/Commentary | Adaptation to Psychiatric Services |
|---|---|---|---|
| Superstructure: Clinician-Patient Level | |||
| Patient and family engagement | Project RED, RARE, TCM | The goal is to achieve active and authentic engagement with the patient, the patient’s family, and other important sources of support and caregiving. One of the most important ways of doing so is to provide a written discharge plan the patient can understand. | Meaningful engagement in discharge planning, targeting recovery-focused goals, is required. Even if a patient lacks capacity, elicit the patient’s opinion and consider informed assent. Consider shared decision making. |
| Comprehensive discharge planning and risk assessment throughout hospital stay | RARE, TJC | “Each patient and family/friend caregiver has a discharge risk assessment completed during the hospital stay, usually within the first 24–48 hours of admission. Discharge planning begins immediately after admission. During the hospital stay, patients are assessed for risk factors that may limit their ability to perform necessary aspects of self-care. Such risk factors include low literacy, recent hospital admissions, multiple chronic conditions or medications, and poor self-health ratings. Also, clinicians begin to assess risks that may be present at the receiving setting. For example, the clinician should confirm that the patient will have access to medications he or she needs at the next setting, as the pharmacy formulary there may not have the medications, or the ability to compound medications as ordered” (3, 25). | Risk assessment will help identify dynamic risk factors that can be mitigated, ranging from suicide and violence risk to supported housing and employment needs. Specialized issues also exist for discharge of the forensic patient back to the jail or prison setting. |
| Assess patient’s degree of understanding of the discharge plan | Project RED | Use teach-back techniques to assess the patient’s understanding of the plan. This may involve shared responsibility with family members or other caregivers. | Assess the patient’s capacity to understand and follow through with TOC. |
| Education | Project RED | Educate the patient about his or her diagnosis, discharge planning, and treatment. Meet with the patient, family, and other caregivers to provide education and begin discharge preparation. | Psychoeducation models can be individualized on the basis of patient factors, for example, the Program for Relapse Prevention (26) and coordinated specialty care for early psychosis (27). |
| Medication reconciliation | Project RED, TJC | Review all medicine lists with the patient, including, when possible, the inpatient medicine list, the outpatient medicine list, the outpatient pharmacy list, and what the patient reports taking. Medications on these lists should include vitamins, herbal medicines, or other dietary supplements the patient takes. Explain what medicines to take, emphasizing any changes in the regimen. Review each medicine’s indication; how to take each medicine correctly; and important side effects and food interactions, if applicable. Ensure a realistic plan for obtaining medicines is in place. Assess the patient’s concerns about the medicine plan. | Standardize medication reconciliation in the outpatient mental health system, too. |
| Assistance with medication self-management | CTI, guided care model, RARE, TCM | This includes education and promotion of self-management and medication self-management. | Shared decision making can further support medication adherence. |
| Ascertain need for and obtain language assistance | Project RED | Assess preferred languages for oral communication and written materials. Once patient and caregiver English proficiency are determined, arrange for language assistance as needed, including translation of pertinent written materials. | Language assistance and cultural approaches are important not only for the patient but also for family members, proxy decision makers, and other caregivers. |
| Plan for follow-up of pending lab or study results | Project RED | Identify the lab work and tests that have pending results. Discuss which clinician will be reviewing the results, as well as when and how the patient will receive information. | |
| Make appointments for follow-up medical appointments and postdischarge tests and lab work | Project RED | Based on the follow-up needs (primary care and specialty), choose providers informed by patient preference—for example, in terms of gender, location, specialty, and health plan participation—and make follow-up appointments with providers and for tests with patient input for best time and date. Educate the patient on the plan and the importance of following through, then assess understanding. Inquire about traditional healers, and make an effort to reconcile traditional healing and conventional medicine methods so they are complementary. Assess any roadblocks to appointments (e.g., child care, transportation) and problem solve. | Care coordination of appointments, including scheduling coordination, can be helpful with or without the support of psychiatric case management. |
| Organize postdischarge outpatient services and medical equipment. | Project RED | Coordinate medical equipment services with case management, including at-home services and social supports, in collaboration with the medical team and case managers. Document the arrangements in the discharge plan. | |
| Crisis planning: Review with the patient what to do if a problem arises and develop a crisis plan. | Project RED, CTI, TJC | A pillar of Coleman’s CTI model is developing with the patient a list of red flags indicative of a worsening condition and instructions on how to respond to them. | Psychiatric advance directives can be a person-centered strategy to operationalize crisis planning and integrate such planning into the health care system. Wellness recovery action plans are recovery-based self-management systems that includes crisis planning (28). |
| Timely follow-up, support, and coordination postdischarge | CTI | Follow-up appointments should be scheduled at the time of discharge to occur within seven days. | Individualize and integrate care to mitigate transition failures associated with follow-up appointments, including timeliness and access |
| Bridge communication with the patient | TJC | Provide telephone reinforcement of the discharge plan. Bridge coordinators contact the patient within two days to conduct a secondary assessment and identify any needs. | |
| Bridge coordinator and bridge support | Australian Southern Mental Health (29), CTI, bridge model, RARE | The bridge model supports contact with the patient within two days to conduct a secondary assessment and identify needs, as well as to provide additional tracking to address any emerging needs. Coleman’s CTI has transition coaches who foster care coordination and continuity of care via a series of visits and telephone calls. | Peer support specialists can serve as bridgers in a recovery-oriented program such as New York’s NYAPRS Peer Bridger Project (30) and Washington State’s RI Peer Bridger Program (31). Mental Health America provides a summary of peer bridger services (32). |
| Multidisciplinary communication, collaboration, and coordination from admission through transition | TJC, RARE | Support both a culture of collaboration and standardization of handoff communication. | |
| Readmission analysis | TJC | The treatment team should conduct a timely analysis of the readmission that involves the patient and family to determine possible causes for the rehospitalization, including financial, transportation, or caregiver problems. The analysis drives improvements for the TOC for the patient, family, friends, and caregivers. | Include in the readmission analysis a structured assessment of risk factors and risk reduction factors (resiliency), and target reduction of the dynamic risk factors and strengthening of resiliency in the treatment plan, discharge plan, and crisis plan. |
| Substructure: Organizational Level | |||
| Shared accountability | TJC, TCM | Clinician involvement and shared accountability during all points of transition. | |
| Prospective modeling | BOOST, bridge model, TCM | The hospital identifies patients who would be most at risk for postdischarge complications and targets them with risk-specific interventions. Screening tools include the Society of Hospital Medicine’s risk assessment tool, the 8Ps (33), which can be used with the Project BOOST Program; the Canadian-developed LACE index (34); the computerized algorithm HOSPITAL (35) that focuses on medical TOC risk; the Pra instrument (36); and the United Kingdom’s PARR algorithm (37) and PARR–30 model (38) to identify patients at risk of readmission within 30 days (39). | A well-validated risk assessment tool focusing on persons with psychiatric illness with ability to adapt to setting and individual factors would be useful. Address comorbidity with behaviors, illnesses, and other risk factors, which may increase risk for failures in TOC—for example, history of rehospitalization, being a superutilizer, suicide risk, violence risk, treatment nonadherence, first-episode psychoses, high medical comorbidity, incarceration related to mental illness or alcohol or substance use, borderline or dependent personality traits, malingering, forensic considerations (e.g., those adjudicated not guilty by reason of insanity), or discharge against medical advice. |
| Care pathways and specialized collaborative delivery care models | ACT, GRACE, TCM | The collaborative, integrated GRACE model targets low-income seniors with a team led by both a nurse practitioner and a social worker. TCM is a nurse-led, multidisciplinary model for chronically ill, high-risk older adults. | Develop clinical decision support and care pathways, individualized to local regions, that structure focused service options for high-risk populations as noted above under Prospective modeling, such as ACT access with fidelity. Consider assisted outpatient treatment if clinical and legal criteria are met (40). |
| Support information transfer of patient health information | CTI | One of the four pillars of Coleman’s CTI model is “a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer” (41) | Remove barriers to communication. Some corporate compliance infrastructure can err on the side of risk aversion and not allow communication of protected health information, which can increase safety risk and impair TOC. The U.S. Department of Health has released clarification of the HIPAA Privacy Rule as it relates to sharing information on mental health (42). |
| Access to community-based services | TJC, CTI, guided care model | This involves organizational support of access with expectations of the standard follow-up appointment with a clinician within seven days of discharge (43). | In a setting with a shortage of psychiatric nurses and psychiatrists (44, 45), extenders may be used to attempt to bridge the gap and serve as leaders of treatment teams. The lack of access to psychiatrists may affect TOC for patients with severe mental illness (46). Access to psychiatric services within seven days postdischarge when clinically indicated—as well as other community-based services—should be an outcome measure expectation. |
| Expedite transmission of discharge summary to clinicians accepting care of the patient | Project RED | Deliver discharge summary and After Hospital Care Plan to clinicians within 24 hours of discharge. | |
| Quality measurement and feedback: Evaluate TOC measures and fidelity with procedures | TJC, ARC model, NTOCC | Gather data of key components of TOC and provide feedback to stakeholders on both side of the bridge, including patients, with the goal of improving quality in a culture of safety and learning. Use root cause analysis if a sentinel event associated with TOC occurs; use proactive risk assessment—for example, failure mode and effects analysis—to improve TOC; use lean management and other high reliability strategies. The Case Management Society of America convened the NTOCC to develop recommendations for TOC measures (47). | Use data to analyze opportunities for improvement at the clinician level but also the system level with consumer involvement. Outcome measures might include time to first treatment, time to first psychiatric appointment, show rates, crisis plan development rates, transfer of discharge summary information, medication reconciliation, 30-day readmission, and boarding of psychiatric patients readmitted. |
| Standardized transition plans, procedures, and forms | TJC | Standardization should support clinicians in doing their work with fidelity to best TOC practices and not burden clinicians with wasteful steps and alert fatigue. | |
| Standardized TOC training | TJC | Each organization defines successful TOC. Training targets the key steps in TOC with real-time performance feedback. TOC is made an organizational priority and a performance expectation. ACGME, medical school, nursing school, and all other health care education training organizations should include TOC competencies in their curricula as well as training in understanding the risks associated with transitions and how the learners can contribute to a safe TOC. | Support clinician training and competencies. Consider including key TOC elements in psychiatrist-focused and ongoing professional performance evaluations. The mental health system is often fragmented; therefore, standardize TOC for the mental health system and not just a single organization. |
| Caregiver support | Guided care model | Assess caregiver needs and provide support. The model is designed to reduce family caregiver strain. | Caregiver strain is a challenge for family members and other caregivers. Reducing strain might thereby strengthen support. |
| Foundation Level | |||
| TOC research funding and support | NIMH, AHRQ | More controlled studies are needed on TOC, especially with a focus on serving persons with mental illness in psychiatric and other inpatient settings with attention to the effectiveness of the components and the system engineering elements. For example, although postdischarge telephone calls are widely used to reduce readmission rates, a systematic review by Crocker et al. showed that “despite the growing use of primary care–based telephone follow-up in the postdischarge period, there are no high-quality studies demonstrating its benefit” (48). | |
| Standards and measures to support best practice integrated, collaborative | TJC, URAC, CMS | TJC enterprise is working on furthering safety and quality in TOC. However, accreditation organizations often only survey one organization within a system; the standards, elements of performance, and national patient safety goals are often siloed within accreditation programs. URAC supports integrated service models with standards. CMS has meaningful use core measures, which focus on TOC (49). Hospital-based inpatient psychiatric service measures that target TOC also exist, for example, actions such as creating a postdischarge care plan and transmitting that care plan to the next level of care provider upon discharge (50). CMS quality measures for 2017 merit-based incentive programs will include TOC measures (51) like postdischarge medication reconciliation and follow-up after hospitalization for mental illness. | TJC does have Behavioral Health Home Certification under its Behavioral Health Care Program (52). Additional efforts could occur in meeting the TOC needs of persons with mental illness within all programs. Challenges exist with surveying TOC if one organization is accredited and others are not. |
| Fund best practice models for TOC | The CMS Quality Improvement Program will use merit-based incentive programs and advanced alternative payment models to reimburse (53). | ||
| Fund integrated and collaborative care with incentives for TOC conditions of participation, standards, and outcomes | The collaborative care model of integrating primary care and behavioral health has several core components that could ensure safer TOCs, including a behavioral care manager, a registry to track engagement and progress, and a weekly caseload review between the care manager and a psychiatric consultant to make treatment changes for patients who are not improving. | Although the collaborative care model has been around for 15 years, no consistent funding mechanisms have been available, which has been a significant obstacle to widespread adoption. However, beginning January 1, 2017, new CPT codes are available to fund this model, and more implementation is anticipated as these codes start first with Medicare and then experience more widespread adoption in Medicaid and private payer sectors. | |
a
Sources (3, 17–25, 41, 54, 55). RED, Re-Engineered Discharge training program; RARE, Reducing Avoidable Readmissions Effectively; TCM, transitional care model; ACT, assertive community treatment; CTI, care transitions intervention; TJC, The Joint Commission; BOOST, Better Outcomes by Optimizing Safe Transitions; GRACE, Geriatric Resources for Assessment and Care of Elders; LACE, length of stay, acuity of the admission, comorbidity of the patient, and emergency department use; HOSPITAL, hemoglobin, discharge from an oncology service, sodium level, procedure during the index admission, index type of admission (urgent), number of admissions during the last 12 months, and length of stay; Pra, Probability of Readmission; PARR, patients at risk for readmission; HIPAA, Health Insurance Portability and Accountability Act; ACGME, Accreditation Council for Graduate Medical Education; ARC, Availability, Responsiveness, and Continuity; NTOCC, National Transitions of Care Coalition; NIMH, National Institute of Mental Health; AHRQ, Agency for Healthcare Research and Quality; URAC, Utilization Review Accreditation Commission; CPT, Current Procedural Terminology
Financial pressure has been a driver of the development and use of many of these programs. However, these TOC models and resources do not specifically focus on TOC within the mental health system.
Vigod et al. (56) systematically reviewed 15 studies that focused on reducing early psychiatric readmissions of adults. The authors distilled 15 nonoverlapping structural components, which they organized into three sections of the TOC bridge—the predischarge side, the bridge span itself, and the postdischarge side. The four key components of predischarge in TOC are medication reconciliation and education, structured needs assessment, scheduling follow-up appointment prior to discharge, and psychoeducation. For bridging, the key components are timely communication by inpatient staff with an outpatient care or community service provider after discharge, meeting with the outpatient mental health provider prior to discharge, and use of a transition manager. The transition manager serves the patient best through the TOC on the foundation of a therapeutic alliance begun either prior to hospital discharge or soon after discharge to optimize the transition out of the hospital. At postdischarge, there are eight key components: telephone follow-up, efforts to ensure psychiatric follow-up, psychoeducation, home visits, family education and intervention, structured needs assessment, postdischarge hotline, and peer support.
Vigod and colleagues (56) also commented that although assertive community treatment (ACT) and other forms of intensive case management are not TOC programs per se, evidence indicates that these delivery models are successful in preventing readmission and improving TOC. ACT also has key components of integration and collaboration at its foundation and substructure.
At postdischarge, there are eight key components: telephone follow-up, efforts to ensure psychiatric follow-up, psychoeducation, home visits, family education and intervention, structured needs assessment, postdischarge hotline, and peer support.
Vigod and colleagues (56) also commented that although assertive community treatment (ACT) and other forms of intensive case management are not TOC programs per se, evidence indicates that these delivery models are successful in preventing readmission and improving TOC. ACT also has key components of integration and collaboration at its foundation and substructure.
The National Association of State Mental Health Program Directors has reviewed Care Transition Interventions to Reduce Psychiatric Re-Hospitalizations (54), which specifically focuses on TOC for persons with severe mental illness. The report summarizes a plethora of models and initiatives and comments on the challenge of there not being a single overall theoretical model that identifies the key components of a TOC bridge for persons with mental illness (other than ACT). However, three delivery models appear to have evidence to support successful TOC: case management, involuntary outpatient commitment and compulsory treatment orders, and ACT. Crisis planning is also becoming a key component of the TOC bridge and is especially salient for persons with high risk of relapse, suicide (57), or aggression (58). Another promising approach is the collaborative care model of integrating primary care and behavioral health care. This evidence-based approach to providing effective treatment of behavioral health conditions in primary care settings has several core features that allow for safer TOCs, such as assigning a behaviorally trained care manager to each patient, using a registry to track patient’s engagement so no one is lost to follow-up, and having a consulting psychiatric provider work with the primary care–based team to make treatment recommendations for patients who are not responding to care. A patient involved with the collaborative care model approach will have close monitoring and follow-up as he or she moves into and out of inpatient settings. The patient will also have closer contact at the crucial postdischarge phase, because the primary care team is tracking the patient, anticipating the patient’s return, and meeting weekly with the psychiatric consultant to discuss any needed changes in treatment (59).
Effective navigation of the transition from inpatient to community-based services is critical to patient safety; quality of care; health care cost; and the satisfaction of patients, families, and clinicians. However, the journey out of the hospital for a person with mental illness is not always smooth. TOC requires a functional bridge with structural stability and integration at all levels to support success. Several models have been developed to improve TOC, all with individualized yet somewhat overlapping components. Ongoing study, implementation, and maintained infrastructure funding for effective, integrated, and collaborative TOC for persons with mental illness is needed and well deserved.
Answers
1.
The answer is C. “It is estimated that the readmission rate for discharged psychiatric patients is approximately 40–50% within 1 year of hospital discharge” (60).
2.
The answer is true (61).
3.
The answer is false. “The 5 percent of the U.S. community (civilian noninstitutionalized) population that spent the most on health care accounted for 49 percent of overall U.S. health care spending” (62).
4.
The answer is true. Havassy and Hopkin (63) also showed the number of psychiatric hospitalizations was the strongest predictor of rehospitalization and lengthy hospitalization. In comparison with single-admission patients, several factors might inform risk: chronic unemployment, diagnosis of schizophrenia or affective disorder, and secondary diagnosis of personality disorder. The authors commented on the importance of targeting social disadvantage in the TOC.
5.
The answer is C. “In the USA, fewer than half of discharged patients are connected with outpatient care discharge within 7 days, a widely accepted quality of care indicator” (55).
6.
The answer is D. The Joint Commission noted, “An estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients” (16).
7.
The answers are A, C, and D (and not B or E).
8.
The answer is A. Coleman et al. performed a randomized controlled study of a large integrated delivery system in Colorado that reduced both cost and rehospitalization at 30, 90, and 180 days by using an integrated model that emphasized collaboration among the hospital, nursing facilities, single home health care agencies, and patients (20).
References
1.
Deschamps I, Macedo MG, Eve-Levesque C: University-SME collaboration and open innovation: intellectual-property management tools and the roles of intermediaries. Technology Innovation and Management Review, pp 33–41, March 2013. https://timreview.ca/article/668
2.
Ildan MM: Mehmet Murat Ildan Quotations. muratildanquotations.wordpress.com/. Accessed May 3, 2017
3.
Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care. Oakbrook Terrace, IL, The Joint Commission, The Joint Commission Center for Transforming Healthcare, and Joint Commission Resources, 2012. www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf. Accessed May 3, 2017
4.
Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418–1428. www.nejm.org/doi/pdf/10.1056/NEJMsa0803563
5.
Readmission Reduction Program (HRRP). Baltimore, MD, U.S. Centers for Medicare and Medicaid Services, 2016. www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed May 3, 2017
6.
Hines AK, Barrett ML, Jiang J, et al: Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011. Statistical brief 172. Rockville, MD, Agency for Healthcare Research and Quality, 2014. www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf. Accessed May 3, 2017
7.
Better Care for Super-Utilizers. Princeton, NJ, Robert Wood Johnson Foundation. www.rwjf.org/en/library/collections/super-utilizers.html. Accessed May 3, 2017
8.
Herman D, Conover S, Felix A, et al: Critical Time Intervention: an empirically supported model for preventing homelessness in high risk groups. J Prim Prev 2007; 28:295–312
9.
Qin P, Nordentoft M: Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 2005; 62:427–432. jamanetwork.com/journals/jamapsychiatry/fullarticle/208501
10.
Swartz MS, Swanson JW, Hiday VA, et al: Am J Psychiatry 1998; 155: 226–231. ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.155.2.226
11.
Lamb HR, Weinberger LE: Persons with severe mental illness in jails and prisons: a review. Psychiatr Serv 1998; 49:483–492
12.
Koskinas v. Cuomo. New York, NY, Urban Justice Center. mhp.urbanjustice.org/mhp-koskinas. Accessed May 3, 2017
13.
Humensky JL, Fattal O, Feit R, et al: Factors associated with outpatient visit attendance after discharge from inpatient psychiatric units in a New York City hospital. Psychiatric Services. (Epub ahead of print, Feb 15, 2017). ps.psychiatryonline.org/doi/pdfplus/10.1176/appi.ps.201600150. Accessed May 3, 2017
14.
Tarasoff v. Regents of University of California, 551 P. 2d 334 – Cal: Supreme Court 1976. San Franciso, CA, Supreme Court of California, 1976. scholar.google.com/scholar_case?case=263231934673470561. Accessed May 8, 2017
15.
Massengill G, Martin ML, Davies G, et al: Mass Shootings at Virginia Tech: April 16, 2007. Report of the Review Panel. Richmond, VA, Virginia Tech Review Panel, 2007. governor.virginia.gov/media/3772/fullreport.pdf. Accessed May 3, 2017
16.
Joint Commission Center for Transforming Healthcare releases targeted solutions tool for hand-off communications. Jt Comm Perspect 2012; 32:1–3 www.jointcommission.org/assets/1/6/tst_hoc_persp_08_12.pdf Accessed May 7, 2017
17.
Project RED (Re-Engineered Discharge) training program. Rockville, MD, Agency for Healthcare Research and Quality, 2014. www.ahrq.gov/professionals/systems/hospital/red/index.html. Accessed May 7, 2017
18.
Transitional Care Model. Philadelphia, PA, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing. www.nursing.upenn.edu/ncth/transitional-care-model. Accessed May 7, 2017
19.
Project Boost Mentored Implementation Program. Philadelphia, PA, Society of Hospital Medicine. www.hospitalmedicine.org/Web/Quality_Innovation/SHM_Signature_Programs/Mentored_Implementation/Web/Quality___Innovation/Mentored_Implementation/Project_BOOST/Project_BOOST.aspx. Accessed May 7, 2017
20.
Coleman EA, Parry C, Chalmers S, et al: The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006; 166:1822–1828. caretransitions.org/wp-content/uploads/2015/06/39_The-Care-Transitions-Intervention-Results-of-a-Randomized-Controlled-Trial.pdf
21.
Guided Care: Comprehensive Primary Care for Complex Patients. Baltimore, MD, Johns Hopkins Bloomberg School of Public Health, 2013. www.guidedcare.org. Accessed May 7, 2017
22.
Geriatric Resources for Assessment and Care of Elders (GRACE). Indianapolis, IN, Center for Aging Research, Indiana University, 2016. medicine.iupui.edu/iucar/research/grace. Accessed May 8, 2017
23.
The Bridge Model. Chicago, IL, The Bridge Model National Office. www.transitionalcare.org/the-bridge-model. Accessed May 7, 2017
24.
Transitions of Care (ToC) Portal. Oakbrook Terrace, IL, The Joint Commission, 2016. www.jointcommission.org/toc.aspx. Accessed May 7, 2017
25.
Components of Re-Engineered Discharge (RED). Boston, MA, Boston University School of Medicine, 2014. www.bu.edu/fammed/projectred/components.html. Accessed May 8, 2017
26.
Lamberti JS: Seven keys to relapse prevention in schizophrenia. J Psychiatr Pract 2001; 7:253–259
27.
Dixon LB, Goldman HH, Bennett ME, et al: Implementing coordinated specialty care for early psychosis: the RAISE Connection Program. Psychiatr Serv 2015; 66:691–698. ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201400281
28.
Cook JA, Copeland ME, Jonikas JA, et al: Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning. Schizophr Bull 2012; 38:881–891
29.
Lawn S, Smith A, Hunter K: Mental health peer support for hospital avoidance and early discharge: an Australian example of consumer driven and operated service. J Ment Health 2008; 17:495–508
30.
Peer Bridger Project. Albany, NY, New York Association of Psychiatric Rehabilitation Services, 2017. www.nyaprs.org/peer-services/peer-bridger. Accessed May 7, 2017
31.
Peer Bridger Program. Phoenix, AZ, RI International, 2015. riinternational.com/our-services/washington/peer-bridger-program. Accessed May 7, 2017
32.
Peer Services Toolkit: A Guide to Advancing and Implementing Peer-Run Behavioral Health Services. Alexandria, VA, Mental Health America, 2015. www.mentalhealthamerica.net/sites/default/files/Peer_Services_Toolkit%204-2015.pdf. Accessed May 8, 2017
33.
Risk Assessment – 8P: Project BOOST Implementation Toolkit. Philadelphia, PA, Society of Hospital Medicine, 2014. www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/BOOST_Intervention/Tools/Risk_Assessment.aspx. Accessed May 7, 2017
34.
van Walraven C, Dhalla IA, Bell C, et al: Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ 2010; 182:551–557. www.cmaj.ca/content/182/6/551.full.pdf+html
35.
Donzé JD, Williams MV, Robinson EJ, et al: International validity of the HOSPITAL score to predict 30-day potentially avoidable hospital readmissions. JAMA Intern Med 2016; 176:496–502. jamanetwork.com/journals/jamainternalmedicine/article-abstract/2498847
36.
Novotny NL, Anderson MA: Prediction of early readmission in medical inpatients using the Probability of Repeated Admission instrument. Nurs Res 2008; 57:406–415
37.
Billings J, Dixon J, Mijanovich T, et al: Case finding for patients at risk of readmission to hospital: development of algorithm to identify high risk patients. BMJ 2006; 333:327. www.bmj.com/content/bmj/333/7563/327.full.pdf
38.
Bardsley M, Blunt I, Billings J: How to Implement the PARR-30 Model: Required Data and Algorithm. London, United Kingdom, Nuffield Trust, 2012. www.nuffieldtrust.org.uk/research/how-to-implement-the-parr-30-model-required-data-and-algorithm. Accessed May 8, 2017
39.
Billings J, Blunt I, Steventon A, et al: Development of a predictive model to identify inpatients at risk of re-admission within 30 days of discharge (PARR-30). BMJ Open 2012; 2:e001667. bmjopen.bmj.com/content/bmjopen/2/4/e001667.full.pdf
40.
Swartz MS, Wilder CM, Swanson JW, et al: Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatr Serv 2010; 61:976–981 ps.psychiatryonline.org/doi/pdf/10.1176/ps.2010.61.10.976
41.
Lonowski S: Improving Care Transitions: A Strategy for Reducing Readmissions. Policy Issue Brief. Denver, CO, Center for Improving Value in Health Care, Sept 2012
42.
HIPAA Privacy Rule and Sharing Information Related to Mental Health. Washington, DC, U.S. Department of Health and Human Services, 2014. www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/mhguidancepdf.pdf. Accessed May 7, 2017
43.
Boult C, Leff B, Boyd CM, et al: A matched-pair cluster-randomized trial of guided care for high-risk older patients. J Gen Intern Med 2013; 28:612–621
44.
Japsen B: Psychiatrist shortage worsens amid ‘mental health crisis.’ Forbes (Epub Sept 15, 2015). www.forbes.com/sites/brucejapsen/2015/09/15/psychiatrist-shortage-worsens-amid-mental-health-crisis/#73e69ed848d3. Accessed May 7, 2017
45.
Appelbaum PS: The ‘quiet’ crisis in mental health services. Health Aff (Millwood) 2003; 22:110–116. content.healthaffairs.org/content/22/5/110.full.pdf+html
46.
Stone A, Rogers D, Kruckenberg S, et al: Impact of the mental healthcare delivery system on California emergency departments. West J Emerg Med 2012; 13:51–56. www.ncbi.nlm.nih.gov/pmc/articles/PMC3298229/pdf/wjem-13-01-51.pdf
47.
Transitions of Care Measures. Washington, DC, National Transitions of Care Coalition, 2008. www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. Accessed May 7, 2017
48.
Crocker JB, Crocker JT, Greenwald JL: Telephone follow-up as a primary care intervention for postdischarge outcomes improvement: a systematic review. Am J Med 2012; 125:915–921. www.amjmed.com/article/S0002-9343(12)00474-3/pdf
49.
Stage 2: Eligible Professional Meaningful Use Core Measures, Measure 15 of 17. Baltimore, MD, U.S. Centers for Medicare & Medicaid Services, 2015. www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_15_SummaryCare.pdf. Accessed May 8, 2017
50.
Hospital Based Inpatient Psychiatric Services. Oakbrook Terrace, IL, The Joint Commission, 2013. manual.jointcommission.org/releases/TJC2013A/HospitalBasedInpatientPsychiatricServices.html. Accessed May 7, 2017
51.
Quality Measures for MIPS Quality Category Reporting. Alexandria, VA, American Psychiatric Association, 2017. www.psychiatry.org/psychiatrists/practice/quality-improvement/quality-measures-for-mips-quality-category. Accessed May 7, 2017
52.
Behavioral Health Home Certification. Oakbrook Terrace, IL, The Joint Commission, 2017. www.jointcommission.org/accreditation/behavioral_health_home.aspx. Accessed May 7, 2017
53.
MACRA: Delivery System Reform, Medicare Payment Reform. Baltimore, MD, U.S. Centers for Medicare & Medicaid Services, 2016. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed May 7, 2017
54.
Pincus HA: Care Transition Interventions to Reduce Psychiatric Re-Hospitalizations. Alexandria, VA, National Association of State Mental Health Program Directors, 2015. www.nasmhpd.org/sites/default/files/Assessment%20%233_Care%20Transitions%20Interventions%20toReduce%20Psychiatric%20Rehospitalization.pdf. Accessed May 7, 2017
55.
Viggiano T, Pincus HA, Crystal S: Care transition interventions in mental health. Curr Opin Psychiatry 2012; 25:551–558. www.integration.samhsa.gov/Care_transition_interventions_in_mental_health.pdf
56.
Vigod SN, Kurdyak PA, Dennis CL, et al: Transitional interventions to reduce early psychiatric readmissions in adults: systematic review. Br J Psychiatry 2013; 202:187–194. bjp.rcpsych.org/content/bjprcpsych/202/3/187.full.pdf
57.
Stanley B, Brown GK: Safety planning intervention: a brief intervention to mitigate suicide risk. Cognit Behav Pract 2012; 19:256–264
58.
Henderson C, Flood C, Leese M, et al: Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ 2004; 329:136
59.
Archer J, Bower P, Gilbody S, et al: Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews 10:CD006525, 2012
60.
Bridge JA, Barbe RP: Reducing hospital readmission in depression and schizophrenia: current evidence. Curr Opin Psychiatry 2004; 17:505–511
61.
Jiang HJ, Weiss AJ, Barrett ML, et al: Characteristics of Hospital Stays for Super-Utilizers by Payer, 2012. Statistical brief 190. Rockville, MD, Agency for Healthcare Research and Quality, 2015. www.hcup-us.ahrq.gov/reports/statbriefs/sb190-Hospital-Stays-Super-Utilizers-Payer-2012.pdf. Accessed May 7, 2017
62.
Stanton MW: The High Concentration of U.S. Health Care Expenditures. Research in Action Issue 19. Rockville, MD, Agency for Healthcare Research and Quality, 2006. meps.ahrq.gov/data_files/publications/ra19/ra19.pdf. Accessed May 7, 2017
63.
Havassy BE, Hopkin JT: Factors predicting utilization of acute psychiatric inpatient services by frequently hospitalized patients. Hosp Community Psychiatry 1989; 40:820–823
Information & Authors
Information
Published In
History
Published in print: Summer 2017
Published online: 18 July 2017
Keywords
Authors
Funding Information
Dr. Raney receives royalties from American Psychiatric Publishing and reports no other financial relationships with commercial interests. Dr. Jabbarpour reports no financial relationships with commercial interests.
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).