Patient Education and Hospital

Psychiatric Readmission

Implementation of Strategies to Reduce Psychiatric Readmission

To this end, it is clear that hospital readmission remains a prevalent phenomenon in adult psychiatric patients, placing a huge morbidity and economic burden on individuals, families, and healthcare organizations (Burton, 2012; Machado et al., 2012). Addressing psychiatric readmission, therefore, is an important priority for healthcare providers. Evidence demonstrates that psychiatric readmission is mainly caused by ineffective transition of care from the inpatient to the outpatient setting (Kalseth et al., 2016). In essence, reducing psychiatric readmission requires effective care transition interventions. The purpose of this EBP project is to reduce readmissions in an adult psychiatric hospital by 10% over a three-month period.

Implementation Model

There are several models that provide guidelines for the implementation of practice change. In this case, however, given the nature of the clinical setting and resource availability, Rosswurm & Larrabee's (1999) is deemed an appropriate model. The model suggests six steps for the implementation of evidence-based practice change: 1) assess the need for change in practice; 2) connect the problem with interventions and outcomes; 3) synthesize best evidence; 4) design a change in practice; 5) implement and evaluate change in practice; and 6) integrate and maintain change in practice. On the whole, the model is a useful framework for guiding practice change in nursing and healthcare, and its usefulness is extensively supported by literature (Melnyk & Fineout-Overholt, 2011).

The first step of the model essentially involves collecting internal data and comparing it with external data (Rosswurm & Larrabee, 1999). The data is important for justifying the need for practice change. In this case, for instance, data about psychiatric readmissions at the target setting would be collected and compared with other hospitals in the region or even nationally. The second step involves determining the interventions that may be used to address the problem and specifying the desired outcomes (Rosswurm & Larrabee, 1999). This particularly entails classifying the problem based on standard classification systems and nursing guidelines. This provides further understanding of the problem at hand. In this case, for example, the problem of psychiatric readmission requires effective transition of care from the hospital to the outpatient setting. This can result in outcomes such as readmission rates and increased patient satisfaction. The third step, synthesizing best evidence, builds on the second step. Research evidence justifying the selected interventions and outcomes is located and synthesized (Rosswurm & Larrabee, 1999). This step in this case would entail synthesizing evidence relating to care transition interventions and their effectiveness in reducing psychiatric readmissions.

With synthesized evidence, the next step would be to outline the various processes, activities, and procedures required to implement the change in practice (Rosswurm & Larrabee, 1999). The change in practice is designed specifically considering the available resources and stakeholder feedback. The fourth step is basically the planning stage. In this case, the relevant team would, for example, plan how discharge processes would be conducted, how staff training and education would be carried out, how patients and families would be educated, how follow-up visits would be scheduled, and so forth.

It is important to dwell much more on the fourth step as it is a very crucial step in the practice change implementation process. Eric Coleman's structured Care Transition Intervention (CTI) model provides a suitable framework for designing the change in practice. The model offers useful guidelines for transitioning care from one setting to another, especially from the inpatient setting to the home setting. More specifically, the model is premised on a multifaceted approach grounded on four pillars: medication self-management (ensure the patient has knowledge of medications and how to manage them); patient-centered documentation (ensure the patient maintains their own record for purposes of information sharing across settings); timely follow-up (ensure follow-up visits are completed as scheduled); red flags (ensure the patient has knowledge of signs that indicate their condition is deteriorating and how to respond to them) (Lonowski, 2012). Compared to most transitional care models, CTI is easier and cheaper to implement.

The implementation of the CTI model encompasses two major mechanisms: 1) the personal health record (PHR) and 2) the transition coach (Lonowski, 2012). The first mechanism denotes a patient-centered document owned and kept by the patient. The record facilitates information transfer and care continuity across settings. The second mechanism, which is arguably the most crucial, means empowering patients and caregivers. The transition coach meets with the patient shortly before (at the hospital) and after discharge (at home). In addition, the transition coach constantly follows-up the patient -- through telephone -- throughout the immediately succeeding 30-day post-discharge period. Essentially, the CTI model prioritizes patient and caregiver empowerment. It turns healthcare providers into patient advocates, and gives patients and families the resources and knowledge they require to take control over their own health (Lonowski, 2012).

The fifth step of Rosswurm & Larrabee's (1999) model involves implementing and evaluating the practice change. This particularly entails executing the processes, procedures, and activities defined in the fourth stage. This step, in this case, would, for instance, involve aspects such as visiting patients at home, telephone follow-ups, and providing patients with informational resources. This step would also involve gathering data to examine whether the implemented interventions have achieved the desired outcomes. The results of the evaluation would provide important lessons for the maintenance of the change in practice. The evaluation would enable the organization to identify successes and areas of improvements, paving way for the anchorage of the change in practice into the organization's everyday care processes.

Broadly speaking, implementing the CTI model occurs in two stages: the pre-discharge stage and the post-discharge stage (Lonowski, 2012). The pre-discharge stage is the stage immediately preceding the patient's discharge from hospital. This stage involves a number of processes including post-discharge care planning, staff training, and patient education and engagement. Care planning is an elaborate process undertaken by the multidisciplinary team under the leadership of the case manager. A vital aspect of the plan entails defining the goals and objectives of the intervention. In this case, the overarching objective is to reduce readmission within a psychiatric unit by 10% in three months. The plan also defines actions that will be undertaken to achieve the objective, how the care will be delivered, who will be responsible for what, how staff training will be conducted, the resources that will be required (costs), follow-up visits, and how evaluation will be done. Every aspect of the plan should be based on evidence (Lonowski, 2012).

Staff training is crucial for equipping providers with knowledge about the objectives of the intervention or practice change, the patient's medical history and their needs and goals, the health parameters to monitor, evidence-based practices, how to engage patients, among other aspects. Patient and family education and engagement is also an important element of the pre-discharge process. Engaging the patient is vital for ensuring the designed care plan resonates with their unique needs. Prior to discharge, patients -- together with their family caregivers -- must have extensive knowledge of PHR, what to do and not to do while at home, how to manage medication, what to do if the condition worsens, and so forth.

Family involvement is particularly important at the pre-discharge stage. Members of the patient's family should be prepared for the transition and familiarized with how to handle their loved one while at home. This ensures family caregivers don't feel left out in the process (Eassom et al., 2014). According to Lonowski (2012), there should be coordination between the present and the next site of care. The family setup is one of the major settings where psychiatric patients continue receiving care upon discharge, further underscoring the importance of family involvement.

Following care planning, staff training, and patient education, the post-discharge period commences. This is a particularly important stage. It involves activities such as home visits, hospital visits, and follow-up telephone calls (Lonowski, 2012). During the hospital visit, the provider discusses with the patient the importance of medication, PHR, symptoms, and medication reactions. The provider also recommends follow-up visits. During home visits, the provider looks out for any discrepancies between pre-discharge and post-discharge medication lists, assesses the condition of the patient, discusses symptoms and adverse effects, reviews the PHR and discharge summary, and emphasizes the significance of follow-up visits. Follow-up telephone calls are often important for clarifying any concerns the patient might have as well as reminding patients about sharing their PHR with their provider. Home visits and telephone calls should be made consistently throughout the first 30 days of discharge.

Accountability is essential at every stage of the transition process (Lonowski, 2012). This means roles and responsibilities must be clearly defined to ensure patients constantly have an identifiable provider at their disposal. With clearly defined roles and responsibilities, it becomes easier to hold individuals accountable in the event of the occurrence of undesired outcomes such as medication errors.

Organizational Setting and Stakeholders

The setting for the implementation of the EBP project is an adult psychiatric hospital. The hospital provides inpatient and outpatient services stretching across a broad array of psychiatric disorders, including depression, posttraumatic stress disorder (PTSD), anxiety disorders, borderline personality disorder, and substance dependency. These services are delivered by a competent team of healthcare professionals, including psychiatrists, psychologists, psychiatric nurse practitioners, mental health counselors, and social workers. Though the hospital has done commendably in providing quality psychiatric care, the challenge of readmission abounds. Reducing readmission rates is vital for improving the overall quality of care at the hospital as well as patient satisfaction.

Successful transition of care requires involvement of all the relevant stakeholders (Lonowski, 2012). Rosswurm & Larrabee's (1999) change implementation model particularly recognizes the importance of stakeholder involvement at the first stage of practice change implementation -- evaluation of the need for practice change. Stakeholders may include patients and their families, hospitals, health care professionals, policymakers, as well as post-acute care settings and services such as rehabilitation centers, assisted living residents, home health, and hospice care. Each of these stakeholder groups has an important role to play during the care transition process. For example, hospitals and healthcare professionals are generally involved in planning, administering, coordinating, executing, and evaluating post-discharge care. Post-acute settings are involved in ensuring the discharged patient maintains the desired health status. Indeed, without adequate stakeholder involvement, the expected health outcomes are unlikely to be achieved.

In psychiatric care, families of patients constitute a particularly important stakeholder group. Regrettably, healthcare professionals are often reluctant to involve them in the care of their loved ones (Ewertzon et al., 2010; Eassom et al., 2014; Coleman et al., 2015). Family involvement will be essential if the desired outcomes are to be more effectively achieved. The case manager -- together with other members of the multidisciplinary team, including psychiatric nurse practitioners and counselors -- should extensively involve the families of patients throughout the entire process.

Intervention/Practice Change

An important part of the planning process is to specify the actions to undertake in order to achieve the stated objective. This is the fourth stage of Rosswurm & Larrabee's (1999) model. In the literature review section, it was established that readmissions within the context of psychiatric care have much to do with the characteristics of the hospital environment. Among other aspects, these include the capacity of the hospital and members of staff, staffing levels, discharge planning procedures, outpatient treatment modalities, and the extent to which evidence is integrated into practice (Machado et al., 2012; Kalseth et al., 2016). This means that undertaking changes within the hospital environment will be important for the achievement of the desired outcomes.

Three aspects that require change in this case are staffing, discharge planning, and integration of evidence into practice. At the moment, the hospital is facing a considerable shortage of personnel. This means that most staff members are often overloaded. Excess workloads suggest that each case is not given the attention it requires. Also, understaffing increases the risk of hospital errors. The hospital should, therefore, ensure adequate staffing. The challenge of understaffing is further compounded by ineffective discharge planning processes. While each patient is assigned to a certain manager, the post-discharge care planning process is quite deficient of multidisciplinary collaboration, patient education, and family involvement. Case managers often make all the decisions, with little involvement of other members of the multidisciplinary team. Also, case managers hardly involve family caregivers in the planning process. Patient education is also not rigorous enough. There should be greater collaboration between members of the care team, more extensive patient education, and more engagement of the family (Chugh et al., 2009; Lonowski, 2012). Discharge planning is one of the areas that should be addressed through staff training. Staff training is also crucial for honing staff members' ability to integrate evidence into practice.