Do Stabilization Strategies Prevent Early Readmission? Opportunities for Improvement in Hospital-Based Psychiatric Care for Adolescents

Background and Purpose:

Stabilization is a primary goal of psychiatric hospital care for children and adolescents. Young people are frequently admitted to hospitals because of suicidal and/or homicidal behaviors. Treatment teams, under pressure to keep length of stays short, must quickly assess, treat, and coordinate aftercare. Yet achieving stabilization is extremely challenging, as youth present with severe and chronic problems, multiple psychosocial stressors, and complex medication regimens. Consequences of inadequate stabilization are costly often resulting in readmission, repeat suicide attempts, and discontinuity of care. The purpose of this study is to assess the impact of clinical stabilization strategies—medication management, discharge planning, and aftercare--on adolescents' readmission within 30 days of discharge.

Methods:

Data are from a retrospective cohort study of a sample of 522 Medicaid covered adolescents (aged 11-17) consecutively admitted to three major private psychiatric hospitals in Maryland. Comprehensive data on sociodemographic (age, race/ethnicity, gender), clinical (primary psychiatric diagnosis, comorbidities, suicidal and homicidal behaviors), service history (prior hospitalizations and medications), organizational (hospital provider, length of stay), and inpatient treatment practices (medication regimens, number of medication changes, discharge living arrangements, type of aftercare) were collected from medical records by Master's level social work students who were blind to the purposes of the study. Administrative data from Medicaid paid claims and the Department of the Maryland Department of Health and Mental Health Hygiene were used to extract information on readmissions to any hospital in the state. Relative risks of readmission (hazard ratios and 95% confidence intervals) were estimated using multivariate Cox proportional regression models.

Results:

Twelve percent of adolescents were readmitted within 30 days of discharge. Controlling on sociodemographic and clinical characteristics, two stabilization strategies implemented during the hospital stay significantly reduced the likelihood of early readmission. First, the risk of readmission was reduced by 75% (HR = .25, p < .002), when social workers intervened to change the adolescents' placement at discharge. Of the 139 youths (30%) who experienced a change in placement, 62% moved to a more restrictive living environment, 33% remained the same, and 5% moved to a less restrictive environment. Second, changes in psychotropic medication regimens decreased the likelihood of readmission by 61% (HR = .39, p < .04). The most common type of medication change was the addition of another medication from a different drug class. However, discharge to partial hospitalization programs significantly increased risk of readmission (HR = 2.25, p <. 02).

Conclusions and Implications:

Readmission within one month of discharge from the hospital is a commonly used measure of quality of care. With the advent of managed care and resultant shortened length of stays, hospitals are under increasing pressure to provide timely, efficient, and high quality care. This study demonstrates that stabilization strategies focused on careful discharge planning by social workers and medication management by psychiatrists can reduce early readmission. It also raises questions about the use of partial hospitalization programs as a proxy for needed continued inpatient care. To achieve stabilization and improved quality of inpatient psychiatric care for adolescents, strategic interdisciplinary communication between researchers and practitioners in social work and psychiatry will be necessary.