Translation of a Transitional Care
Model for Individuals with
Serious Mental Illness
Nancy Hanrahan, PhD, RN, FAAN
Associate Professor, School of Nursing
University of Pennsylvania
Investigators & Funding
 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
Background
 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
Known Challenges
 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
Purpose of Study
 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
Transitional Care Model (TCM)
 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.
Background & Significance: 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
Previous Research
 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)
Other Models of Care
 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
Methods
 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
Advisory Group
 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
Methods
 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
Findings
Sociodemographics
 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
Mental and Medical Dx Profile
 Mean # of Medications: 6.1 (3.03)
 Mental Disorders:
 55% Schizophrenia Spectrum
 45% Mood Disorders
 Medical:
Back pain
Hypertension
Arthritis
Seizure Disorder
Diabetes
N
%
11
11
9
7
7
63
58
42
30
30
Elevated Cholesterol
Asthma
Hypothyroid
Hepatitis C
TBI
Cancer
N
%
6
9
3
3
2
2
25
42
15
15
10
10
Outcome Continuity of Care
Continuity of Care: Scheduled and Missed Appointment
Control
n=20
n
%1
•
•
•
Individuals with any scheduled appointment(s) at the
time of discharge (any provider)
Individuals with a scheduled follow up appointment at
discharge with a mental health provider.
Individuals with appointments additionally scheduled
within 90 days of discharge.
Intervention
n=20
n
%1
10
50.0
8
40.0
8
40.0
4
20.0
13
65.0
17
85.0
•
Total # of appointments: Mean (SD)--
44
2.4(1.9)
66
3.4(1.9)
•
Missed appointment rate (all appointments within 90
days of discharge)
13
34.4
17
36.7
Scheduled and missed appointment rates:
Mental Health Professional
Medical Specialist
Primary Care
1Percent
11 (28)
7 (11)
5 (5)
% Missed3 n(#)2
26.9
27.3
0
17 (32)
8 (18)
7 (18)
%
Missed3
12.4
16.7
13.6
of group n=20
the number of individuals who had any appointment—n—and the total number of appointments (#)
2Indicates
3
n(#)2
Outcome: Readmission and ED
Control
n1
Total2
#Admits
n1
Total2
#Admits
p-value
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 #
7
14
6
11
0.313
Psychiatric
1
8
1
4
1.000
Medical
8
6
8
5
0.723
Hospital Readmits
Emergency Use
1
Intervention
The number of participants that had hospital readmission or emergency use.
2 The total number of hospital readmissions or emergency room visits.
Outcome: HRQoL
5 point increase=clinical sig.
 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
Successful Case Example
 Hx – Female hosp. for manic episode; Bipolar, hypertension, noninsulin 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.
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 – 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
Key Findings
 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 Finding
 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
Future Directions
 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