Psychiatric inpatient hospitalization presents a significant challenge for patients, payers, and the overall health care system. This white paper will provide an overview of the causes and impacts of readmissions. It also examines strategies, such as transitional care management, the use of long acting injectable medications, and peer support, that are being implemented to address the problem. Effective inpatient treatment and successful transitions to the community are essential for a system that already struggles to meet demand. As noted in the Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide), the industry standard for adequate number of psychiatric beds is 40 to 60 beds per 100,000 people. As a nation, there are only 29.8 beds per 100,000 people. This shortage is only exacerbated by high readmission numbers.1
Readmissions impact overall health care costs and the average per patient cost of care. This is a particularly salient issue for state Medicaid programs, as they are the single largest payers of service for individuals with serious and persistent mental health disorders.2 A 2014 statistical brief released by the Agency for Healthcare Research and Quality (AHRQ) found that four of the top ten conditions with the highest number of hospital readmissions within Medicaid were depression, schizophrenia, alcohol related disorders, and substance abuse-related disorders.3 For Medicaid patients, depression and schizophrenia account for the highest rate of readmissions. For privately insured patients, depression holds the second highest number of 30-day readmissions.3 The AHRQ brief found that just four behavioral health-related conditions accounted for $832 million in Medicaid spending on readmissions. Another AHRQ brief released in 2015 found that the average cost of a 30-day readmission for mood disorders was more expensive than the initial stay, ranging from $700 to $1,300 more.4 Readmissions place further strain on limited inpatient bed capacity. Fortunately, promising strategies for addressing 30-day readmissions are emerging.
Transitional Care Support: The transition between inpatient care and community mental health treatment is a time of high risk for individuals with serious mental illness (SMI) and one that requires significant attention to discharge planning.5 Despite the need for supported transitions of care for individuals with SMI and the high rate of 30-day readmissions for this population, there has been a much larger focus on care transitions for geriatric patients and those with chronic physical health conditions. This focus has led to the development of multiple models of care such as the Coleman Model, the Transitional Care Model (TCM), The Bridge Model, and the Guided Care Model.5 While each model uses a different approach, some commonalities include a focus on assessment of member needs, providing tools, skills, and supports for individuals to better manage their illness, and coordination of care during and after inpatient care. A review of transitional care literature conducted by Harold Pincus, MD, the Co-Director of the Irving Institute for Clinical and Translational Research, Columbia University and Director of Quality and Outcomes Research at New York-Presbyterian Hospital failed to identify specific comprehensive transitional care models specifically applied to mental health.5
Studies have shown that some key factors that increase the risk for readmission include medication nonadherence, unstable post-discharge care environments, substance use disorder comorbidities, and psychosis comorbidities.6 Additional factors include limited access to specialty care, difficulty obtaining medication, less family and social support, language barriers, low health literacy, housing instability, inadequate transportation, and overall poorer health status.6 Transitional care approaches are intended to address a number of these factors.
A systematic review of interventions including pre-discharge, early post-discharge, and those that spanned the transition from inpatient to outpatient care conducted by Vigod, Kurdyak, Dennis, Leszcz, Taylor, Blumberger, and Seitz (2013) revealed that interventions from each of the above categories significantly decreased readmission. Another key finding was that successful programs focused on known modifiable risk for readmission such as poor self-care, difficulty with medication usage, knowledge about disease management, and coordination of care after discharge.7 Overall, the study identified eight effective components of multicomponent interventions.7
- Psychoeducation targeting disease management and living skills
- Structured assessment of patient’s discharge needs
- Pre-discharge medication education/reconciliation
- Post-discharge telephone follow-up
- Efforts to ensure timely follow-up appointments
- Home visits
- Peer support
- Communication by inpatient staff with outpatient care or community service provider during the transition
Other studies have also explored the differences between discharge care for individuals with physical health hospitalizations and mental health inpatient stays. Individuals discharged from inpatient settings for physical health conditions are more frequently discharged with in-home support as compared to those discharged from a psychiatric hospitalization.6 As with other areas of health care, there is also increasing attention being paid to the impact of unmet social determinants of health such as safe housing and employment. Effective approaches to transitional care need to be patient-centered and address these issues as well as connections to community-based treatment resources.
An example of an effective care transition program for behavioral health was developed by Allina Health. Allina Health, an integrated delivery system in Minnesota, provides inpatient and outpatient mental health care to communities throughout Minnesota and western Wisconsin. Using grant funds to develop a pilot, Allina developed a transitional care program that:
- Delivered mental health interventions to enhance the chances of successful recovery in the outpatient setting and subsequently reduce readmissions;
- Improved access to community mental health resources while a patient is still hospitalized;
- Created a patient-centered recovery model that promotes early patient and family engagement in discharge planning;
- Improved patient advocacy in treatment and demonstrated improvements in patient experience; and
- Improved communication between inpatient and outpatient resources to ensure best care transitions and follow-up.8
Allina also implemented two new roles to support transitions, mental health navigators and peer support specialists. The mental health navigator is a mental health professional who partners directly with the patient and care team to establish essential outpatient services, enhance discharge planning, support patient-centered recovery initiatives, and conduct routine outpatient follow-up with Minnesota Community Healthcare Network (MCHN) contacts and patients.8 The peer support specialist fosters a trusting relationship with the patient, participates in or runs recovery groups, encourages patients to engage and participate more deeply in care planning, and provides outpatient follow-up to maintain recovery and prevent crises as needed. Hallmarks of the model include proactive patient engagement in the form of patient outreach and care coordination, which begins while an individual is an inpatient and continues for 30-45 days post discharge. Care coordination includes ensuring the hospital record is transmitted to the community provider within 24 hours of discharge. Implementation of this enhanced care transition model led to a 4.6% 30-day readmission rate for program participants, significantly below the national 30-day readmission rate for schizophrenia, 15.7%, and mood disorders 9.0%.
Long Acting Injectables: Another intervention that has shown promise to reduce readmissions is the use of long acting injectable (LAI) medications for the treatment of schizophrenia. Although not directly listed as an intervention within the Vigod et al. (2013) study, there is a growing body of research that supports the use of LAI antipsychotic medications to address medication adherence challenges and reduce 30, 90, and 180-day readmission.
Individuals with schizophrenia have the second highest rate of 30-day readmissions of all of the major diseases.3 Hospitalization and rehospitalization is often driven by a combination of factors that impact the course of the illness, such as co-morbid substance use disorders, criminal justice involvement, unstable housing, poverty, and lack of social supports.9 These issues also impact the ability for individuals with schizophrenia to remain adherent to medication regimes.10 The Paliperidone Palmitate Research in Demonstrating Effectiveness (PRIDE) study, designed to look at the impact of injectable medications in “real world settings”, compared paliperidone palmitate and oral antipsychotics on treatment failure in subjects with schizophrenia.11 Treatment failure was defined as any one of the following: arrest/incarceration, psychiatric hospitalization, suicide, discontinuation of antipsychotic treatment due to inadequate efficacy, treatment supplementation with another antipsychotic due to inadequate efficacy, discontinuation of antipsychotic treatment due to safety or tolerability concerns, or an increase in the level of psychiatric services to prevent imminent psychiatric hospitalization. The study found that the median time to treatment failure was 416 days for individuals receiving the LAI compared to 226 days for individuals taking oral antipsychotics. The most common reasons for treatment failure in the study was arrest/incarceration and hospitalization, with a higher percentage of individuals on oral antipsychotics experiencing these issues.11
Another real-world example of the impact of LAIs on hospital readmissions is seen in data provided by Molina regarding the inpatient unit readmission rate of the OSF Heart of Mary Hospital in Champaign, Illinois. The unit’s readmission rate was 2.2% compared to the regional rate of 22%. Dr. Feiteng Su, the Chief Psychiatric Director of the hospital reports a very high percentage of his patients are discharged on a LAI.12
Peer Support: Studies of the impact of peer support have found that services delivered by individuals with histories of mental illness are comparable in effectiveness to those provided by mental health professionals.13 In a study on the effectiveness of peer support to reduce readmissions for individuals with multiple psychiatric hospitalizations, researchers found that individuals who received peer support delivered using a modified version of the peer companion model had significantly fewer admissions and significantly fewer hospital days.13 A 2017 brief created by Mental Health America highlighted similar impact of peer support programs citing the effectiveness of the Optum Pierce Peer Bridger program at decreasing readmissions. It also noted the success of the Peer Bridger model created by the New York Association of Psychiatric Rehabilitation Services. The model led to a 47.9% decrease in the number of people who used inpatient services, a decrease in inpatient days, and an increase in the number of outpatient visits by program participants.14
As outlined above, despite multiple challenges faced by individuals with SMI that often lead to rapid hospital readmission, there are promising approaches that are reducing readmissions. Access and cost pressures are likely to continue to impact psychiatric inpatient utilization. Promotion of improved care transitions support, addressing social determinants of health, greater use of LAIs, and peer support models will be essential to reduce rapid rehospitalization and promote recovery for individuals with SMI.
About The Guide
The Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide) provides information and insights into the multi-layered United States behavioral health system. The Guide includes an in-depth view of current statistics, prevailing issues, and emerging trends in order to inform the discussions, debates and decision-making of policy-makers, payers, providers, advocates and consumers. The Guide addresses current behavioral health care trends topics, including:
- A look at the national policy that is shaping the U.S. health and human services market
- A view of the state behavioral health delivery systems that were created by a combination of historical practices, federal and state policy, and market factors over recent years
- An examination of the practices of 1,265 health plans that manage both physical and behavioral health care for the vast majority of the U.S. population
- A deep-dive into behavioral health care access and delivery of care from the consumer perspective
Otsuka America Pharmaceutical, Inc. & Lundbeck, LLC. (2019). Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System. Rockville, MD: Otsuka America Pharmaceutical, Inc. Retrieved from PsychU.org
(nd). Behavioral health services. Retrieved from https://www.medicaid.gov
Hines, A. L., Barrett, M. L., Jiang H. J., & Steiner, C. A. (2014). Conditions with the largest number of adult hospital readmissions by payer, 2011. Healthcare Cost And Utilization Project, 172. Retrieved from https://www.hcup-us.ahrq.gov
Heslin, K. C., & Weiss, A. J. (2015). Hospital readmissions involving psychiatric disorders, 2012. Healthcare Cost And Utilization Project, 189. Retrieved from https://www.hcup-us.ahrq.gov
National Association of State Mental Health Program Directors. (2015). Care transition interventions to reduce psychiatric re-hospitalizations. Retrieved from https://www.nasmhpd.org
Zink, A. (2018). Mental health patients, with nowhere else to go, are overwhelming emergency departments. Stat. Retrieved from https://www.statnews.com
Vigod, S. N., Kurdyak, P. A., Dennis, C. L., Leszcz, T., Taylor, V. H., Blumberger, D. M., & Seitz, D. P. (2013) Transitional interventions to reduce early psychiatric readmissions in adults: Systematic review. BJPsych, 202, 187-194. doi: 10.1192/bjp.bp.112.115030
(2017). Enhancing mental health care transitions reduces unnecessary costly readmissions. Retrieved from https://www.healthcatalyst.com
OPEN MINDS. (2014). What drives Medicaid behavioral health readmission rates? Retrieved from https://www.openminds.com
Molfenter, T., Connor, T., Ford, J. H., Hyatt, J., & Zimmerman, D. (2016). Reducing psychiatric inpatient readmissions using an organizational change model. WMJ. Retrieved from https://www.wisconsinmedicalsociety.org
Alphs, M., Benson, C., Cheshire-Kinney, K., Lindenmayer, J., Mao, L., Rodriguez, S. C., & Starr, L. (2013). Real-world outcomes of Paliperidone Palmitate compared to daily oral antipsychotic therapy in Schizophrenia: A randomized, open-label, review board–blinded 15-month study. The Journal Of Clinical Psychiatry, 76, 05. Retrieved from https://www.psychiatrist.com
Sutker, I. (2019, August 29). Interview by D. Adler. OPEN MINDS. Gettysburg, PA.
Sledge, W. H., Lawless, M., Sells, D., Wieland, M., O’Connell, M. J., & Davidson, L. (2011). Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations. Psychiatry Online. Retrieved from https://ps.psychiatryonline.org
Mental Health America. (2017). Evidence for peer support. Retrieved from https://www.mentalhealthamerica.net
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