Reducing Psychiatric Readmissions: Care Transition Interventions

Introduction and Purpose

The purpose of this evidence-based practice project is to examine ways to reduce psychiatric readmissions. More specifically, literature is reviewed to evaluate evidence supporting the effectiveness of care transition interventions in preventing re-hospitalization among adult patients with severe mental illness. This paper first describes the search process, then summarizes and synthesizes the identified literature, clearly evaluating its relevance to the specified PICOT question.

Search Process

Literature for the review was searched in CINAHL, PubMed, EBSCO, ProQuest, and Google Scholar databases using the following phrases: psychiatric readmission, re-hospitalization, care transition interventions, transitional care interventions, and reducing readmission in adults with mental illness. Focus was particularly on literature published in English. From the first round of searching, it was evident that the topic has received relatively limited scholarly attention, as the search returned fewer than 1,500 hits.

The second stage of the search process involved narrowing results to literature published within the last five years, informed by the need to obtain the most current evidence. The third stage focused on eliminating unpublished theses or dissertations, newspaper articles, and conceptual articles. Given the nature of the project — integrating evidence into practice — emphasis was placed on scholarly articles, particularly randomized controlled trials (RCTs), case studies, surveys, systematic reviews, meta-analyses, peer-reviewed technical briefs, and evidence-based clinical practice guidelines. These sources tend to be more authoritative than other source types.

The final stage involved a thorough evaluation of article titles, abstracts, and full content. In the end, six articles were included in the review: four systematic reviews and two technical briefs. The findings of these articles are summarized and synthesized in the sections that follow.

Risk Factors for Psychiatric Readmission

Understanding the risk factors for psychiatric readmission is essential. Without this understanding, interventions for minimizing readmission may not be effectively planned, designed, or implemented. In a systematic review of 35 articles — including both interventional and observational studies — Kalseth et al. (2016) reveal that psychiatric readmissions are significantly associated with patient attributes, health system factors, and environmental factors. These factors fall into three broad categories: regulatory and governance structures (e.g., healthcare financing and interdependence between primary care and community providers); capacity and organization of healthcare providers (e.g., hospital policy, bed capacity, staffing levels, length of stay, and discharge planning procedures); and environmental factors (e.g., location of the hospital or patient, and community demographics such as unemployment rates and income). A major strength of Kalseth et al.'s (2016) review is the fairly large number of studies included. Nonetheless, as the review primarily focused on factors associated with psychiatric readmission, it offers limited insight into care transition interventions specifically.

Factors relating to healthcare providers are particularly important predictors of readmission risk. Poor discharge and transition planning, ineffective interdisciplinary collaboration, resource constraints, deficient documentation of patient needs, poor communication with patients and their families, and insufficient patient education on the part of healthcare providers can all increase the likelihood of psychiatric readmission (Allen et al., 2014; Pincus, 2015).

The fact that health system factors significantly predict readmission risk implies that healthcare providers — both practitioners and organizations — have a crucial role to play in offering effective care transition interventions. The concept of transitional care interventions generally refers to care activities aimed at ensuring quality, effective, safe, and timely care when patients are being transferred across different levels and settings of care (Viggiano, Pincus, & Crystal, 2012). While transitions occur in various forms, this review focuses specifically on the transition from inpatient care to outpatient care, which mainly revolves around activities conducted during the pre-discharge stage at the hospital and the immediate post-discharge stage in the community setting (Allen et al., 2014).

Administered often as components of long-term integrated care, transitional care interventions are typically aimed at avoiding or reducing re-hospitalization in patients with chronic conditions. It is important to note, however, that though transitional care is an element of integrated care, it is a conceptually distinct type of care (Allen et al., 2014). Transitional care generally involves communication among members of the interdisciplinary team about the discharge process and care in the next setting, preparing the patient for the transition, planning follow-ups, reconciling medications, and equipping the patient with self-management education (Viggiano, Pincus, & Crystal, 2012; Vigod et al., 2013; Gaynes et al., 2015). This can help prevent or minimize adverse events that occur during and after transition, such as medication and diagnostic errors, non-compliance with medications, falls, post-surgery infections, and substance abuse (Pincus, 2015).

Overview of Care Transition Models

Transitional care interventions are informed by a number of established models. In their review of literature obtained from websites, public databases, and reports authored by government agencies, private sector entities, and national organizations with an interest in psychiatric care, Viggiano, Pincus, and Crystal (2012) sought to review current care transition models for both general medical and mental health populations. According to the review, models specifically targeting the mental health population are few compared to those targeting general medical populations.

The few models specific to mental conditions include Eric Coleman's Care Transition Intervention (CTI) model, the Transitional Care Model (TCM), Minnesota's Reducing Avoidable Readmissions Effectively (RARE) model, Better Outcomes for Older Adults through Safe Transitions (BOOST), the Geriatric Resources for Assessment and Care of Elders (GRACE) model, the Guided Care Model, and the Bridge Model. These models have been shown to be effective in reducing psychiatric readmissions (Viggiano, Pincus, & Crystal, 2012).

Literature has further documented the effectiveness of transitional care interventions in improving care outcomes for older adults, particularly in relation to re-hospitalization. In a systematic review of 12 randomized controlled trials reporting quality outcomes for transitional care interventions aimed at older adults with chronic illness transitioning from hospital to home care, Allen et al. (2014) found that the interventions used in most studies were effective in reducing readmissions as well as length of stay. Only interventions premised on primary care nurse and general practitioner models were found to be less effective in minimizing readmission. The review further found that the interventions positively impacted care efficiency and equity, care safety, timeliness, patient-centered care, and patient satisfaction.

One of the major strengths of Allen et al.'s (2014) review is that all included articles were RCTs, which were thoroughly assessed for bias. RCTs are widely regarded as the most authoritative and rigorous sources of evidence, which enhances the credibility of the review. Nonetheless, the relatively small number of articles included is a notable limitation, and the review focused on care transition interventions for chronic illness in general rather than psychiatric complications specifically. This somewhat limits the generalizability of the findings to the psychiatric population. Even so, the study offers important insights into the usefulness of care transition interventions — particularly in terms of not only reducing readmission rates, but also enhancing other quality outcomes such as efficiency, equity, timeliness, and safety.