Translation of a Transitional Care Model for Persons With Severe Mental Illness

Background: Some of the highest rates of hospital readmission within 30 days of discharge occur with adults who have serious mental illnesses (SMI).  Today, hospital stays for a psychiatric illness average 10-11 days and many discharged patients remain in an acute phase of their illness which can often mean they continue to be vulnerable for a range of adverse health events.  Frequently they have limited or no support resources to assist with complicated medical regimes and multiple medical and mental health appointments.  Therefore, offering a transitional care model during the hand-off from hospital to home is likely to be beneficial for persons with SMI and comorbid medical problems.

Objective: We translated an evidence-based Transitional Care Model (TCM) for older adults being released from acute care hospitals for patients with SMI and medical co-morbidities being discharged from acute care hospital psychiatric units (TCare).

Methods: An advisory group of community stakeholders assessed barriers and facilitators to using TCare. Implementation of an RCT of a 90-day T-Care intervention by a psychiatric nurse practitioner with supervision and consultation from a psychiatrist versus usual care (generally medication monitoring and case management) was utilized to determine implementation issues. Forty individuals with SMI and medical problems were recruited from 2 psychiatric units. Interviews were conducted at baseline, 6 and 12 weeks to assess use of emergency services and rehospitalizations. 

Results: TCare had higher medical and psychiatric readmissions and fewer emergency room visits than the usual care group. Personal barriers included complex mental and physical health needs, conflict-ridden relationships and unstable housing. System barriers included misinterpretation and inappropriate application of privacy laws and lack of access to clinical data and poor communication across medical and mental health systems.

Conclusions:  The Psychiatric Nurse Practitioner has the skills to translate, advocate, and provide timely health services for patient’s mental and physical health needs across sectors.  Social welfare needs and relationship issues are demanding and require the skills of a social worker and peer provider. We recommend a TCare team approach (nurse, social worker, and a peer with supervision and consult from a psychiatrist) to address the holistic needs of patients which would be blending of a modified Critical Time Intervention, designed for the SMI population transitioning from shelters or hospitals to the community with TCM focusing on medical needs. With these modifications and increased system-wide awareness, ninety days of TCare following an acute episode of a mental illness should provide optimal access to timely care, need-based use of health and social services, and better patient outcomes. Given an increasing recognition of a necessity to integrate behavioral health and medical services for those with SMI, since their morbidity is on average 25 years sooner than the general population, there is a pressing need for effective integrated intervention models. TCare has the potential for wider applicability for the SMI population, such as those on hospital medical units where they have inordinate long lengths of stay due to the inability to find appropriate community settings that can meet their post-hospital medical needs.