Reducing Psychiatric Readmission: EBP Implementation Strategies

Introduction

Hospital readmission remains a prevalent phenomenon in adult psychiatric patients, placing a significant morbidity and economic burden on individuals, families, and healthcare organizations (Burton, 2012; Machado et al., 2012). Addressing psychiatric readmission is therefore 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). Reducing psychiatric readmission consequently 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 and Framework

Several models provide guidelines for the implementation of practice change. Given the nature of the clinical setting and resource availability, Rosswurm and Larrabee's (1999) model is deemed the most appropriate. The model suggests six steps for implementing 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 the change in practice; and (6) integrate and maintain the change in practice. The model is a useful framework for guiding practice change in nursing and healthcare, and its usefulness is extensively supported in the literature (Melnyk & Fineout-Overholt, 2011).

The first step essentially involves collecting internal data and comparing it with external data (Rosswurm & Larrabee, 1999). This data is important for justifying the need for practice change. In this case, data about psychiatric readmissions at the target setting would be collected and compared with other hospitals in the region or 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 entails classifying the problem based on standard classification systems and nursing guidelines, which provides further understanding of the problem at hand. In this case, the problem of psychiatric readmission requires effective transition of care from the hospital to the outpatient setting, yielding outcomes such as reduced readmission rates and increased patient satisfaction.

The third step — synthesizing best evidence — builds on the second. Research evidence justifying the selected interventions and outcomes is located and synthesized (Rosswurm & Larrabee, 1999). In this case, that would entail synthesizing evidence relating to care transition interventions and their effectiveness in reducing psychiatric readmissions. With synthesized evidence in hand, the next step is to outline the various processes, activities, and procedures required to implement the change in practice (Rosswurm & Larrabee, 1999). The change in practice is designed with consideration of available resources and stakeholder feedback. This fourth step is essentially the planning stage. 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, and how follow-up visits would be scheduled.

Care Transition Intervention: Design and Mechanisms

The fourth step of the model warrants particular attention, as it is a crucial stage 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 in four pillars: (1) medication self-management — ensuring the patient has knowledge of their medications and how to manage them; (2) patient-centered documentation — ensuring the patient maintains their own record for purposes of information sharing across settings; (3) timely follow-up — ensuring follow-up visits are completed as scheduled; and (4) red flags — ensuring the patient can recognize signs that their condition is deteriorating and knows how to respond (Lonowski, 2012). Compared to most transitional care models, CTI is easier and less costly 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 PHR is a patient-centered document owned and maintained by the patient that facilitates information transfer and care continuity across settings. The transition coach — arguably the most crucial mechanism — is focused on empowering patients and caregivers. The coach meets with the patient shortly before discharge (at the hospital) and after discharge (at home), and follows up by telephone throughout the 30-day post-discharge period. Essentially, the CTI model prioritizes patient and caregiver empowerment. It transforms healthcare providers into patient advocates and gives patients and families the resources and knowledge they need to take control of their own health (Lonowski, 2012).

The fifth step of Rosswurm and Larrabee's (1999) model involves implementing and evaluating the practice change. This entails executing the processes, procedures, and activities defined in the fourth stage — for instance, visiting patients at home, conducting telephone follow-ups, and providing patients with informational resources. This step also involves gathering data to examine whether the implemented interventions have achieved the desired outcomes. The results of the evaluation provide important lessons for the maintenance of the change in practice by identifying successes and areas for improvement, paving the way for anchoring the change 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 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, reducing readmission within a psychiatric unit by 10% in three months. The plan also defines the actions to be undertaken, how care will be delivered, who is responsible for each component, how staff training will be conducted, the resources required, follow-up visit schedules, and how evaluation will be conducted. Every aspect of the plan should be grounded in evidence (Lonowski, 2012).

Staff training is crucial for equipping providers with knowledge about the objectives of the intervention, the patient's medical history and their needs and goals, the health parameters to monitor, evidence-based practices, and how to engage patients effectively. Patient and family education and engagement is equally important during the pre-discharge process. Engaging the patient is vital for ensuring the care plan resonates with their unique needs. Prior to discharge, patients — together with their family caregivers — must have a thorough understanding of the PHR, what to do and not do while at home, how to manage medication, and what to do if their condition worsens.

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 support their loved one at home, ensuring family caregivers do not feel excluded from the process (Eassom et al., 2014). According to Lonowski (2012), there should be coordination between the current and the next site of care. The family setting is one of the major environments in which 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 stage involves activities such as home visits, hospital visits, and follow-up telephone calls (Lonowski, 2012). During hospital visits, the provider discusses the importance of medication, the PHR, symptoms, and medication reactions, and recommends follow-up appointments. During home visits, the provider looks for any discrepancies between pre-discharge and post-discharge medication lists, assesses the patient's condition, discusses symptoms and adverse effects, reviews the PHR and discharge summary, and emphasizes the significance of follow-up visits. Follow-up telephone calls are important for clarifying any concerns the patient may have and for reminding patients to share their PHR with their provider. Home visits and telephone calls should be conducted consistently throughout the first 30 days following discharge.

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

References

Burton, R. (2012). Improving care transitions. Health Policy Brief. Health Affairs.

Chugh, A., Williams, M., Grigsby, J., & Coleman, E. (2009). Better transitions: improving comprehension of discharge instructions. Frontiers of Health Services Management, 25(3), 11–32.

Coleman, E., Roman, S., Hall, K., & Min, S. (2015). Enhancing the care transitions intervention protocol to better address the needs of family caregivers. Journal of Healthcare Quality, 37(1), 2–11.

Eassom, E., Giacco, D., Dirik, A., & Priebe, S. (2014). Implementing family involvement in the treatment of patients with psychosis: a systematic review of facilitating and hindering factors. BMJ Open, 4, e006108.

Ewertzon, M., Lutzen, K., Svensson, E., & Andershed, B. (2010). Family members' involvement in psychiatric care: experiences of the healthcare professionals' approach and feeling of alienation. Journal of Psychiatric & Mental Health Nursing, 17, 422–432.

Kalseth, J., Lassemo, E., Wahlbeck, K., Haaramo, P., & Magnussen, J. (2016). Psychiatric readmissions and their association with environmental and health system characteristics. BMC Psychiatry, 16, 376.

Kulesher, R., & McSweeney-Feld, M. (n.d.). Chapter 3: Transitions of care and post-acute care services. Retrieved from

Lonowski, S. (2012). Improving care transitions: a strategy for reducing readmissions. Policy Issue Brief.

Machado, V., Leonidas, C., Santos, & Souza, J. (2012). Psychiatric readmission: an integrative review of the literature. International Nursing Review, 59, 447–457.

Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: a guide to best practice. Lippincott Williams & Wilkins.

Rosswurm, M., & Larrabee, J. (1999). A model for change to evidence-based practice. Journal of Nursing Scholarship, 31(4), 317–322.