Background and Significance: Hospital readmissions represent complex inefficiencies in care delivery systems that impact national cost structures. Adults hospitalized for serious mental illness (SMI) have high rates of rehospitalization upon discharge. Transitional care programs (TCPs) are innovative approaches to addressing breaks in health services and potential ways to keep the psychiatric patient from being rehospitalized. Additionally, it is hoped the TCP reduces the number of days of rehospitalization. Commercial insurance does not currently offer transitional care services to their participants. The TCP examined in this study seeks to utilize a transitional care-based approach to services for their commercially insured high-risk for rehospitalization psychiatric participants. It is based on the Medicaid home care model that links care services to high-risk psychiatric populations to after care services, in order to ensure continued provision of care, while reducing hospital readmission rates and days hospitalized.
Purpose and Goals: This project evaluates the effect of a specific TCP on hospital rates and days hospitalized among a targeted number of patients. Its goals are to 1.) Describe program participant demographics for a specified time period; 2.) Evaluate selected statewide psychiatric hospitalization rates and days hospitalized for a specified time period; 3.) Measure dropout and completion rates to assess patient participation in the program over a specified time period.
Methodology: This project employs a retrospective chart review using a consecutive sampling method that includes all clients that have agreed to participate in the program from January 1, 2016 through December 31, 2016. Program participant's hospitalization rates and days hospitalized will be assessed at 6, 12, and 18 months during and up to a 1-year post entry period.
Results: A total of 286 records for Program year 2016 were reviewed. One record was of those 286 was excluded due to incomplete information, leaving 285 records for data analysis. Data was analyzed using descriptive statistics, Bayesian models, and linear regression techniques. Demographics of the participants by gender showed 55% males, 44% females, and 1% transgender persons. The greater percentage for each variable assessed were as follows: 92% were hospitalized in the year prior, to include inpatient or outpatient hospitalization; 88% of participants were Caucasian; 68% were unmarried; 77% did not live alone; 48% were employed; 70% had ever used substances; 63% used substances within the last year; 43% had suicidal ideation in the past; and 54% had suicidal ideation within the past year. The majority of participants were not re-hospitalized while in the Program (71%); most of the participants stayed in the Program for up to 6 months (40%), with a small number (6%) of participants staying in the Program more than 18 months. There were more females (13%) than males (7%) that were re-hospitalized, with the majority of total days of re-hospitalization being under 30 days. The top 5 diagnoses in either the first or second diagnosis category were: depression disorders (41%), anxiety disorders (48%), bipolar disorders (13%), alcohol use disorders (10%), and opioid use disorders (3%). There were more females (45%) than males (37%) with depression disorders, and a fairly close percentage of females (49%) and males (46%) with anxiety disorders, as well as bipolar disorders (13%) females and (12%) males. There was a difference in alcohol use disorders among males (15%), then females (7%), but relatively equal percentages among males and females having opioid use diagnoses (4%) and (4%) respectively. The majority of participants (43%) staying in the Program under 6 months. Females that stayed in the Program the longest had depression disorders (46%), whereas males who stayed in the Program the longest also included more schizophrenia disorders (40%). Comparison of participants days hospitalized with days spent in the Program indicated that the majority of participants were rehospitalized less days in the first 6 months of being in the Program, but more days if they are in the Program greater than 18 months. The percent of participants needing an extension of services beyond the 12-month Program date were greater among females (18%), than males (17%). Factorial analysis showed clear profiles of why participants completed or dropped out of the Program. Profiles showed more females used substances and were suicidal throughout the Program than males. Reasons for both completion or not for females and males centered around whether participants lived alone, used substances at any time, or were suicidal in the past year. Reasons for dropping out of the Program are lists the majority (41%) of participants being lost to follow up.
Recommendations: 1). Implement targeted educational and outreach interventions, specifically for female participants with known past psychiatric hospitalizations, depressive disorders, past or present suicidal ideation, and past or current substance use; as these participants may be the highest risk group for rehospitalization. 2). Work with participants on plans for eventual discharge and begin this planning on entry into the Program. Enhance participant coping skills and independence at the start of Program participation and throughout. 3). Target weekly outreach by one or more team members in an effort to keep all participants engaged in the Program. Offer psycho-education to all participants on the importance of maintaining sobriety. 4). Engage with participants and help them feel comfortable on reporting their suicidal thoughts to any team member. Encourage using suicide Hotline number as needed 24/7. Provide coping skills for those with suicidal ideation, early on into the Program. 5). Consider reducing the amount of time participants spend in the Program to 6 months or less, and by the same token transition to community services sooner. 6). Train team members on the importance of recognizing that a TCP is not a long-term solution to provision of psychiatric care; and in some cases, stabilization is the highest level that can be achieved. 7). Engage participants in employment and socialization opportunities midway into the Program, not at the end. These opportunities may affect participants sense of worth and possibly reduce risks for rehospitalization while in the Program.
Conclusion: Analyses indicate that those participants who are male are more likely to abuse alcohol than females, and are less likely than females to complete this type of Program. It showed that more females had suicidal ideation, and females who were rehospitalized for the longest period of time had suicidal ideation and substance use throughout time in Program. This combination of suicidal ideation and substance use in females may indicate a higher risk for rehospitalization. One of the most important finding is that those participants who stayed in the Program longer were more likely to be rehospitalized than those that completed the program in 6-12 months. In some cases, these psychiatric patients studied may have utilized rehospitalization as part of their treatment, particularly if a detox was required or an additional suicide attempt was made. Additionally, these participants could have personality disorders that led to dependence issues that may have impacted rehospitalization. These key findings are significant in that they can help Program administrators and providers tailor their efforts to help participants successfully complete the Program, and more effectively transition to their communities. But, of course to also keep them from being re-hospitalized.
Implications for the Future: Results from this project will inform best practices for advanced practice nurses (APNs), utilizing TCPs as a cost-saving support strategy for commercially insured patients as they re-enter the community. APNs utilizing this approach are philosophically, ethically, and educationally poised to help integrate, collaborate, and expand care and services for this high-risk population.
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