Lessons learned from a pilot RCT to test the effect of a Transitional

Care Model for improving post hospital outcomes for individuals

with serious mental illness

Nancy P. Hanrahan, PhD, RN, FAANDr. L. Kurlowicz Memorial Term Chair

Associate Professor Psychiatric Mental Health Nursing Center for Health Outcomes and Policy Research

University of Pennsylvania School of Nursing

Investigators & Funding

Funded by Robert Wood Johnson Nurse Inquiry program for 18 months

Co-PI – Phyllis Solomon, Ph.D. Professor, School of Social Policy & Practice, University of Pennsylvania

Co- Investigator: Matthew Hurford, M.D. Assistant Professor, Dept of Psychiatry, University of Pennsylvania

Disclosures

No Disclosures to report

Need for Innovative Models of Care

Chronic illnesses cause disability and death for 133 Million Americans1

• 78% of the total U.S. health care spending goes to treat chronic illness

Serious Mental Illness (SMI) + medical comorbidities are highest need and highest cost. 2-3

• 15 million Americans• Top 5% of Medicaid spending• Annual per person costs of $43,130-$80,374.

1. Institute of Medicine. Living Well with Chronic Illness: A Call for Public Health Action. Washington,DC: The National Academies Press; 2012.

2. Kronick RG, Bella M, Gilmer TP. The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions. Washington, D.C.: Center for Health Care Strategies;2009.3. Coughlin TA, Waidmann TA, Phadera L. Among Dual Eligibles, Identifying The Highest-Cost Individuals Could Help In Crafting More Targeted And Effective Responses. Health Affairs. May 1, 2012 2012;31(5):1083-1091.

Despite this level of investment....

Poor health of SMI is striking Die 25 years earlier than the general

population from treatable illnesses4-5

• 3.4 x die from heart disease of diabetes• 3.8 x die from accidents• 5.0 x die from respiratory ailments• 6.6 x die from pneumonia influenza• 3.8 x die from HIV

4.Colton CW, Mandersheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prevention of Chronic Disease [serial online]. 2006; http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm. Accessed 11/25, 2008.5. Hardy S, Thomas B. Mental and physical health comordibity: Political imperatives and practice implications. International Journal of Mental Health Nursing. 2012;21(3):289-298.

Factors related to poor quality health care for SMI

Patient Factors Provider Factors

System Factors

Patient contributors to poor health

• MH problems lead to inability to navigate health system – amotivation, cognitive deficits, & poor health literacy

• 80% impoverished• Poor nutrition• Unstable housing• High use of tobacco, drug & alcohol use• Lack of exercise• Sedentary life style• Psychotropic meds contribute to health risk

factors: weight gain, insulin resistance & elevated blood glucose & lipids

Provider contributors to poor health High incidence of untreated hypertension, elevated blood

sugar, high cholesterol, & asthma Poor routine preventive services Poor quality medical care contributor to excess morbidity &

mortality MH clinicians lack of knowledge & comfort with medical

issues MH clinicians lack of time & resources to deal with medical

issues Primary care providers lack of knowledge & comfort with

SMI population Clinical demands of primary care providers make it difficult

in dealing with co-morbidities When SMI receive medical care, generally do not receive

care that meets clinical guidelines

System Contributors to Poor Health

MH facilities do not provide medical care due to financing challenges & lack of expertise

Fragmentation of systems – health, mental health, & substance abuse silos of c are

Complexity of MH & Health systems – different financing & policies – don’t communicate with each other

Consequently

Lack of coordinated care across systems

High use of hospitals & ED – very costly

Increasing recognition of need for integration of medical & behavioral health care

Transitional Care Model

Transitional Care Model (TCM)- an EBP medically ill elderly (Naylor, 1999, 2000, 2004)

TCM – uses advance practice nurse to manage care of high risk clients from hospital to home

20 years of study show significant improvements in outcomes & reduced costs for high risk clients, particularly with chronic illnesses

TCM and SMI

TCM limited examination for patients with SMI Although evidence of costly cycling in & out of

hospital during exacerbation of illness of those with SMI

High cost of hospitalization in period of shrinking health care resources

Likely preventable rehospitalizations Discharge from hospital opportune time to

intervene for patients with co-morbid medical problems

Research Questions

Purpose of study – to answer following questions:• Does TCM compared to usual care improve

hospital to home outcomes (eg. Reduced rehosp. & ED use, & increase links to community mental health) for discharged patients with SMI and medical comorbidities?

• Is it feasible to implement & modify TCM for discharged patients with SMI?

• What are the barriers & facilitators to implementing & sustaining this model?

Methods

Pilot RCT Control Group (n=20) treatment as usual (case

management provided by CMHAs) Experimental group (n=20) Psychiatric Nurse

Practitioner intervention, met with patient prior to discharge, met immediately after discharge, home visits, ongoing phone calls, accompany to medical & mental health appointments, contact medical & mental health providers, medication management, last 3 months

Methods

Eligibility criteria:• 18-65• SMI – schiz, bipolar, & major affective disorders• Major medical problem, diabetes,

cardiovascular problems, cancer, etc. Recruitment: 2 inpatient psychiatric units

from general hospital in Philadelphia• RA sat in on daily team meetings (psychiatrist,

residents, nurses & discharge social worker) to screen for eligible patients for study

Methods

Outcomes• Medical & psychiatric readmissions• Emergency room use• Links to community mental health

providers Analysis

• Formal statistical tests not conducted due to small sample size

Sample Characteristics

Sample Characteristic Control (N=20) Intervention (N=20)

Age mean, SD 45.8 ,SD=11.9 44.1, SD=11.2

Income (past month) 711.2, SD=430.1 716.6, SD=458.4

Sample CharacteristicsControl (n=20)

Intervention (n=20)

N % N %

GENDER Male 10 50 11 55

RACE AA 9 45 9 45

WhiteOther

74

3520

65

3025

ETHNICITY Hisp/Latino 2 10 1 5

MARITAL STATUS

SingleMarriedDivorcedSeparatedWidowed

153200

75151000

123221

601510105

Sample CharacteristicsControl (n=20)

Intervention(n=20)

Education Less than HS11 55 8 40

HS 4 20 6 30

Post HS tech2 10 0 0

Some college2 10 5 23

College Grad 1 5 0 0

EmployedSome Grad.Yes

02

010

13

515

Sample Characteristics

Current Living Situation ControlN=20

InterventionN=20

N % N %

Home, hotel, apartment

With family

With friends

Emergency Shelter

Halfway House, Board & care

No regular place to live

12

1

1

3

2

1

60

5

5

15

10

5

12

3

0

2

1

2

60

15

0

10

5

10

Psychiatric Diagnoses

Diagnosis Control(n=20)

Intervention (n=20)

N % N %

Mood 8 40 9 45

Major Depressive Disorder 5 25 5 25

Bipolar Disorder 10 2 10

Depression, NOS 1 5 2 10

Psychosis 12 60 11

55

Schizophrenia Schizoaffective Disorder Psychosis, NOS

26

4

103020

560

2530 0

Medical Comorbidities

Medical Diagnosis ControlN=20

InterventionN=20

N % N %

Cardiovascular DiseaseRespiratory IllnessNeurological Disorders: seizureGastro-Intestinal: GERDEndocrine: DiabetesCancerHIVHepatitis CHepatitis B

14 8 3 5 7 3 3 2 0

7040152535151510 0

12 7 6 311 0 0 2 1

6035301555 0 010 5

Psychiatric & Medical Comorbidities

Statistic Control

Intervention

Psychiatric Medical Psychiatric Medical

Mean 0.7 3.65 0.5 2.5

Min 0.0 1.0 0.0 1.0

Max 3.0 7.0 2.0 6.0

SD 0.92 1.68 0.69 2.3

Successful Case Example Hx – Female hosp. for manic episode; Bipolar, hypertension,

non-insulin dep. Diabetes, rectal cancer, seizure disorder Barriers – overwhelmed with medical problems, appts, primary

support finance with active substance abuse problem Facilitators – motivated to get well, providers appreciated APN APN Intervention – ed. On med. Dx & medications, coor.

prescription refills, recommendations of medication with primary care physician, accompanied to medical & psychiatric appts, coor. Hosp. admission for chemo with other appts

Outcome – successfully completed medical tx for rectal cancer, reconnected with Primary care physician & outpatient psychiaty and no psychiatric rehops.

Unsuccessful Case Example Hx – 49 yrs Caucasian male; admitted for being physically

aggressive & pushing boarding home staff member; Schiz paranoid; traumatic brain injury & seizure disorder

Barriers – cognitive impairment & thought disorder – difficulty communicating; Boarding home unlicensed & eventually shut down

Facilitators – initially contact with ICM good – but overtime less responsive; reconnected to outpt psychiatry, primary care physician & neurologist

APN Int. – difficulty with anxiety & sleeping at Bd home – APN prescribed medication; educated staff on behavioral management; initial contact with ICM

Outcome – readmitted to hosp. after going to new residence & reporting suicidal ideation to psychiatrist- very aggressive while in hosp.; discharged from hosp. but returned same day - remained hosp. until end of intervention

Results: Service Utilization

Links with Community Following Index Hospitalization

Table 3.0 Links with Community following Index Hospitalization

Intervention Control P value

n % n %

Any Appointment at Discharge

16 80.0% 19 95.0% .151

Attended Discharge Appointments

17 85.0% 15 75.0% .720

Lost to Follow-up 2 10.0% 3 15.0% .633

Lessons Learned

Complexity/acuity of need Conflict-ridden/highly intense

relationships Unstable housing Tracking patients HIPAA laws and confidentiality issues Cross-system Ambassador

Recommendations T-Care is a feasible model with revisions….

• Transitional Care Team: Advanced Practice Psychiatric Nurse Practitioner, Professional Social Worker, and Peer Support

• Integrated care approach with nurse as Ambassador• Recruit from both medical and psychiatric settings• Measures: add care coordination, longitudinal clinical

and cost measures up to two years• HIPAA implementation reform• Clinical data integration• Integrate Transitional Care Model into the system.