Translation of a Transitional Care Model for

Individuals with Serious Mental Illness

Nancy Hanrahan, PhD, RN, FAANAssociate Professor, School of Nursing

University of Pennsylvania

Funded by Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI).

No conflict of interest. Co-PI – Nancy Hanrahan, Ph.D, Associate Professor,

School of Nursing, University of Pennsylvania Co-PI – Phyllis Solomon, Ph.D., Professor, School of

Social Policy & Practice, University of Pennsylvania Co- Investigator, Matt Hurford, M.D. at time Assistant

Professor, Dept of Psychiatry, University of Pennsylvania

Investigators & Funding

SMI vulnerable after discharge from hospitalization Especially for those with medical co-morbidities High rates of rehospitalization, use of emergency room, homelessness, & lack of mental

health treatment connection

Poor Health of Population: Die 25 years sooner than general population (Colton & Manderschied, 2006) from treatable &

preventable illnesses High incidence of untreated hypertension, elevated blood sugar, high cholesterol, & asthma Poor routine preventive services Poor quality medical care

Medical comorbidities – highest need & highest cost Top 5% of Medicaid spending Annual per person costs $43,130 - $80,374

Background

Transitional Care Model (TCM)- an EBP for medically ill elderly

uses an advance practice nurse Designed for elderly medical patients 20 years of study show significant improvements

in outcomes & reduced costs for high risk clients, particularly those with chronic illnesses

Background

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

Background

Patient Factors MH problems lead to poor navigation of the health system

– amotivation, cognitive deficits, & poor health literacy System Factors

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

Fragmentation of systems – health, mental health, & substance abuse silos of care

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

Known Challenges

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

to home outcomes (eg. Reduced rehosp. & ED use, & increase connection to community mental health) for discharged patients with SMI?

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

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

18 month study

Purpose of Study

Transitional care – broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, & promote safe & timely transfer of patients from one setting to another (Naylor, Aiken, Kurtzman, et al, 2011) Emphasis on educating patients & family

caregivers to address root causes of poor outcomes & avoid preventable rehospitalizations.

Transitional Care Model (TCM)

Essential Elements of TCM• APN primary coordinator of care – assure

consistency of care across episode • In-hospital assessment & develop EBP plan of care• APN home visits with ongoing telephone support

(7 days per wk) for 90 days• Continuity of medical care between hosp. &

primary care physician facilitated by APN accompanying patient to follow-up visits with physician

Background & Significance: TCM

More recently in Canada & Scotland conducted Transitional Discharge Model (TDM) for psychiatric patients being released from hospital Included peer support Extension of inpatient (nurse)-practitioner (public

health nurse in community) relationship prior to discharge

Nurse/ inpatient staff portion – 0-12months until community providers establish relationship with patient

Peer support aspect continues for as long as a year 2 RCTs – one small & one large sample

Previous Research

Small sample in Scotland – reduced readmission & symptoms, & improved functioning (Reynolds, et al, 2004)

Larger sample in Canada – no difference on readmission, emergency room use, quality of life (except social relations – focus of intervention)

- Length of hospital stay for experimental participants was shorter (Forchuk, 2005)

Both studies interventions were less transitional – longer term in some aspects – inpatient transition & peer support

Previous Research

Other transitional care models less medically oriented but more social service oriented post discharge from hospital, specifically, Critical Time Intervention (CTI)

CTI – 9 month intervention to support persons with SMI from institution to community living

Prevent adverse outcome by strengthening ties to services, family, & friends by providing practical & emotional support by CTI worker

Recent RCT study of formerly homeless persons discharged from 2 state hospitals to community – CTI versus usual care Rehosp. significantly less for CTI than usual care (Tomita &

Herman, 2012)

Previous Research

ACT – self contained team approach Team – psychiatrist, nurse, case managers, &

other specialists May start while patient still in the hospital Japan – J-ACT – did this

Ongoing services, high intensity – not transitional service

Other Models of Care

Pilot RCT—40 participants 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, 3 months duration

Methods

Key stakeholders: Consumers, public administrators, nurses, doctors (inpatient care), primary care doctor, home health nurses, and insurance representatives.

Tasked to review and help modify TCM for the SMI

Tasked to identify barriers and facilitators to implementation of TCM

Met monthly throughout the study

Advisory Group

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

problems, cancer, etc. Recruitment: 2 inpatient psychiatric units within a

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 Health-related Quality of Life Medical & psychiatric readmissions Emergency room use Continuity of Care

Analysis Content analysis of Advisory Group meetings

and case studies. Statistical tests of between group differences

Methods

Findings

Sample: Mean age 44.1 55% male 45% African American 60-75% single 40-55% less than a high school education 20-30% unstable housing Mean income of $717 per month 75% unemployed

Sociodemographics

Mean # of Medications: 6.1 (3.03) Mental Disorders:

55% Schizophrenia Spectrum 45% Mood Disorders

Medical:

Mental and Medical Dx Profile

N %

Back pain 11 63Hypertension 11 58Arthritis 9 42Seizure Disorder

7 30

Diabetes 7 30

N %

Elevated Cholesterol

6 25

Asthma 9 42Hypothyroid 3 15Hepatitis C 3 15TBI 2 10Cancer 2 10

Outcome Continuity of CareContinuity of Care: Scheduled and Missed Appointment

Control n=20

Intervention n=20

n %1 n %1

• Individuals with any scheduled appointment(s) at the time of discharge (any provider)

10 50.0 8 40.0

• Individuals with a scheduled follow up appointment at discharge with a mental health provider.

8 40.0 4 20.0

• Individuals with appointments additionally scheduled within 90 days of discharge.

13 65.0 17 85.0

• Total # of appointments: Mean (SD)-- 44 2.4(1.9) 663.4(1.

9)• Missed appointment rate (all

appointments within 90 days of discharge)

13 34.4 17 36.7

Scheduled and missed appointment rates: n(#)2 % Missed3 n(#)2

% Missed3

Mental Health Professional11 (28) 26.9

17 (32) 12.4

Medical Specialist 7 (11) 27.3

8 (18) 16.7

Primary Care 5 (5) 0

7 (18)

13.6

1Percent of group n=202Indicates the number of individuals who had any appointment—n—and the total number of appointments (#)3Missed appointment rate=# individuals who missed an any appointment/# individuals with any appointment

Outcome: Readmission and ED

  Control Intervention

  n1 Total2

#Admitsn1 Total2

#Admits p-value

Hospital Readmits 4 7 10 20 0.112

Psychiatric 4 7 9 14 0.088

Medical 0 0 4 4 0.014

Chemical 0 0 2 2 0.235

   n  Total # n  Total #   

Emergency Use 7 14 6 11 0.313

Psychiatric 1 8 1 4 1.000

Medical 8 6 8 5 0.723

1 The number of participants that had hospital readmission or emergency use.2 The total number of hospital readmissions or emergency room visits.

Physical Function, role limitation (physical), body pain, role limitation(emotional), mental Health showed a 5 point increase in both groups.

Intervention showed a 10 point increase in general health compared with a 4 point increase for the control group.

No other between group differences

Outcome: HRQoL5 point increase=clinical sig.

Hx – Female hosp. for manic episode; Bipolar, hypertension, non-insulin dep. Diabetes, rectal cancer, seizure disorder

Barriers – overwhelmed with medical problems, appts, primary support fiancé 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 psychiatry and no psychiatric rehosp.

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

APN Int. – difficulty with anxiety & sleeping at Boarding 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

Unsuccessful Case Example

TCM may reduce emergency room use

Continuity of Care may improve with TCM

HRQoL- general health may improve with TCM

Recommendation: Need further study of TCM

Key Findings

Advanced practice psychiatric nurse practitioner Translator and ambassador role More valued in the medical sector than mental health sector Prescribing authority-frequent need to fill lost Rx and treat urgent

symptoms. Much time spent tracking patients and assisting with housing/social

needs. Social needs complicate medical and mental/substance use issues.

Recommendations: Integrate model into system Team approach with a advanced practice psychiatric nurse

practitioner, a social worker, a peer specialist, and a consulting psychiatrist

Key Finding

Engagement is key Difficult to engage and conflict-ridden

relationships.

Recommendation: Greater integration of TCM early in the

admission Recovery approach Ensure housing placement

Key Finding

Eligibility for TCM Those with an active medical problems seemed

the most responsive to the nurse intervention, therefore likely to have benefited the most.

Recommendation: Recruit from medical side. Focus recruitment on patients with functional

problems related to medical issues

Key Finding

Poor Communication and coordination among siloed systems a major barrier

Restrictive confidentiality policies combat stigma but prevent coordinated care

Recommendation: Electronic MR needs to be patient-centered. Implied consent approach e.g., circle of care

Key Finding

Larger study

Target medical side to recruit for the intervention

Team approach

Integrate TCM into hospital process to ensure more

time meeting with patient prior to hospital release

Future Directions