Systematic Review and Interventions

Evidence-Based Practice Project: Reducing Rate of Psychiatric Readmission

The purpose of the evidence-based practice project is to examine ways to eliminate psychiatric readmissions. More specifically, literature is reviewed to examine evidence supporting the effectiveness of care transition interventions in preventing re-hospitalization amongst adult patients with severe mental illness. In this chapter, the search process is first described. Next, the identified literature is summarized and synthesized, clearly evaluating the relevance of the literature 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 search, it was quite evident that not much scholarly attention has been given to the topic as the search returned less than 1,500 hits. The second stage of the search process involved narrowing down to literature published in the last five years. This was informed by the need to obtain the most recent evidence on the topic.

In the third stage, focus was on eliminating unpublished theses or dissertations as well as newspaper and conceptual articles. Given the nature of the project, which involves integrating evidence into practice, it was important to focus more on scholarly articles, particularly randomized controlled trials (RCTs), case studies, surveys, systematic reviews, meta-analyses, peer-reviewed technical briefs, as well as evidence-based clinical practice guidelines. These sources tend to be more authoritative compared to other sources. The final stage of the search process involved a thorough evaluation of article titles, abstracts, and content. In the end, six articles were included in the review: four systematic reviews and two technical briefs. The findings of the articles are summarized and synthesized in the immediately succeeding section.

Synthesis of Literature

It is first important to understand the risk factors for psychiatric readmission. Indeed, without this understanding, interventions for minimizing psychiatric readmission may not be effectively planned, designed, and implemented. In a systematic review of 35 articles (interventional and observational studies), Kalseth et al. (2016) reveal that psychiatric readmissions are significantly associated with not only patient attributes, but also health system and environmental factors. These factors fall in three broad categories: regulatory and governance structures (e.g. health care financing and interdependence between primary care and community providers); capacity and organization of health care 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 as well as community demographics such as unemployment rates and income). A major strength of Kalseth's et al. (2016) review is the fairly large number of studies included. Nonetheless, as the review primarily focused on factors associated with psychiatric readmission, it offers little knowledge about care transition interventions.

Factors relating to health care providers are particularly important predictors of the risk for psychiatric readmission. Indeed, poor discharge and transition planning, ineffective interdisciplinary collaboration, resource constraints, deficient documentation of patient needs, poor communication with patients and their families, as well as inattention to patient education on the part of health care providers can increase the possibility of psychiatric readmission (Allen et al., 2014; Pincus, 2015).

The fact that health system factors significantly predict the risk of psychiatric readmission implies that health care providers (practitioners and organizations) have a crucial role to play in offering effective care transition interventions. The notion of care transition interventions or transitional care interventions generally denotes care interventions 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 fall in different categories, this review focuses specifically on transition from inpatient care to outpatient care. This transition mainly revolves around care activities conducted during the pre-discharge stage at the hospital and the immediate post-discharge stage at the care setting Allen et al., 2014).

Administered often as components of long-term integrated care, transitional care inventions are usually aimed at avoiding or reducing re-hospitalization in patients with chronic conditions. It is, however, important to note that though it is an element of integrated care, transitional care is a conceptually different type of care (Allen et al., 2014). Transitional care generally involves communication amongst 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 avoid 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).

Transitional care interventions are informed by a number of models. In their review of literature obtained from websites, public databases, and reports authored by the government, private sector entities, and national organizations with an interest in psychiatric care, Viggiano, Pincus & Crystal (2012) sought to review current care transition models for general medical populations and mental health populations. As per 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 Transition 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 people, 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, and transitioning from hospital to home care, Allen et al. (2014) found that the interventions employed 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 on care efficiency and equity, care safety, timeliness, patient-centered centeredcare, and patient satisfaction.

One of the major strengths of Allen et al.'s (2014) review is that all articles included in the review were RCTs, which were thoroughly assessed for bias. Indeed, RCTs are regarded as the most authoritative and rigorous sources of evidence. This enhances the credibility of the review. Nonetheless, the fairly small number of articles included is one of the major limitations of the review. Further, the review focused on care transition interventions for chronic illness in general as opposed to psychiatric complications. This somehow limits the generalizability of the findings to the psychiatric population. Even so, the study offers important lessons for 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.

Literature focusing specifically on mental illness has also demonstrated the effectiveness of care transition interventions in addressing the problem of re-hospitalization. In a technical brief prepared for the National Association of State Mental Health Program Directors (NASMHPD) and with the support of the Department of Health and Human Services' Center for Mental Health Services, Pincus (2015) reports that care transition interventions can effectively reduce psychiatric readmissions. The report relied on a wide range of sources, including websites, public databases, as well as reports authored by the government, private sector entities, and national organizations. A notable strength of the report is that it answers a broad array of questions in relation to the design and implementation of care interventions for mental illness patients transitioning from inpatient to community settings. These are aspects not quite clear in other reviews (e.g. Allen et al., 2014; Vigod et al., 2013).

Pincus (2015, p. 2) particularly answers the "what", "for whom", "where", "by whom", "when", and "how" questions of transitional care planning and administration. With reference to a number of care transition models, including Eric Coleman's model, the Transition Care Model, and the Guided Care Model, Pincus provides important aspects that ought to be observed to ensure effective continuity of care for patients with mental disorders. These include patient-centered documentation of care elements, a structured checklist of key activities for empowering patients at the pre-discharge stage, follow-up visits, self-management coaching, and awareness of red flags. Other important aspects include screening, care coordination, interdisciplinary collaboration, building the provider-patient relationship, symptom management, family engagement, peer support, evidence-based care planning, feedback, caregiver support, as well as access to community-based resources. Also, highlighted by Gaynes et al. (2015), these aspects are indeed important when planning and implementing transitional care interventions for psychiatric patients.

Similar to Allen et al. (2014), Vigod et al. (2013) sought to evaluate the effectiveness of transitional care interventions in reducing psychiatric readmissions. Their review revealed that care transition interventions in inpatients with mental illness reduced the risk of readmission by 13.6-37%. This was achieved via structured evaluation of patient needs, provision of psychoeducation at the pre- and post-discharge stages, medication education and reconciliation, telephone follow-ups, home visits, family involvement, as well as effective coordination and communication between inpatient and outpatient providers. The review included 15 primary studies conducted in developed countries (RCTs, non-RCTs, and cohort studies). The studies were carefully evaluated for bias, which is a major strength of the review.

Nonetheless, though Vigod et al. (2013) included a larger number of primary studies compared to Allen et al. (2014), Vigod et al.'s (2013) review had a much smaller sample size as most of the studies included had smaller samples. This is an important limitation as far as the generalizability of the findings is concerned. Even so, this does not necessarily weaken the strengths of the findings as all the studies included an intervention and a control group. Vigod et al.'s (2013) review particularly reinforces the findings of Pincus (2015) by highlighting important components of transitional care interventions. An important take away is that the incidence of psychiatric readmission is likely to be successfully reduced if adequate attention is paid to the pre-discharge period, the period immediately after discharge, and long-term follow-up.

The effectiveness of transitional care interventions in reducing psychiatric readmissions is further addressed by Gaynes et al. (2015) in a technical brief prepared for the Agency for Healthcare Research and Quality (AHRQ). Relying on published and unpublished literature as well as informant interviews (with mental health practitioners, health researchers, payers, policymakers, and patient advocacy groups), the authors sought to describe and contrast four strategies for managing psychiatric readmissions. These include length of stay for inpatient care, support services during transition (care administered as the patient moves from inpatient to outpatient care), temporary alternatives for readmission (quick-fix outpatient care administered as a substitute for inpatient care for patients at an insignificant risk of harm to self and/or others), and long-term techniques for minimizing psychiatric admission. The study found that elements of the different interventions are significantly interdependent.