Management Strategies to Reduce Psychiatric Readmissions: Technical Brief

Project Summary Title and Description

Title
Management Strategies to Reduce Psychiatric Readmissions: Technical Brief
Description
Background: Repeated psychiatric hospitalizations, affecting primarily those individuals with a serious mental illness, are a substantial problem. Little is known about the effectiveness of different lengths of hospital stay for these patients, transition support services after discharge, or short- or long-term alternatives to psychiatric hospitalization. Purpose: To describe and compare four core management strategies to reduce psychiatric readmissions—length of stay for inpatient care, transition support services (i.e., care provided as the individual moves to outpatient care), short-term alternatives to psychiatric hospitalizations (i.e., short-term outpatient care provided in place of psychiatric hospitalization for those not at significant risk of harm to self or others), and long-term alternatives to psychiatric hospitalization—for patients at high risk of psychiatric readmission. Methods: We searched published and unpublished sources for information about the effectiveness of these strategies. We also interviewed key informants, representing mental health providers, health services researchers, policymakers, payers, and patient advocacy groups, to confirm and augment our findings. Findings: Other than Assertive Community Treatment (ACT), an alternative to psychiatric hospitalization, we did not identify an overall theoretical model that identified key intervention components. Components of the various strategies overlap and are likely interdependent. Evidence suggests that the most commonly measured outcome, psychiatric readmissions, probably undercounts true readmission rates; other measures of well-being and functioning need to be measured. Of the 63 studies that assessed the link between a management strategy and readmission, two addressed LOS, five addressed transition support services, four addressed short-term alternatives to psychiatric hospitalization, and 52 addressed long-term alternatives to psychiatric hospitalization. The bulk of these studies address two interventions: intensive case management (a transitional support service) and ACT. The availability and implementation of the various management strategies can vary substantially across the country. Conclusions: Important next steps include determining (1) the key components, or packages of components, that are most effective in keeping those at high risk of psychiatric rehospitalization functioning in the community; (2) how to accurately measure the most meaningful outcomes; and (3) how to most efficiently apply effective strategies to areas with varying resources.
Attribution
N/A
Authors of Report
N/A
Methodology description
Published Literature Search: An experienced research librarian developed our search strategy (Appendix B). Given that contemporary resources, finances, and needs relevant to psychiatric hospitalization have changed substantially from approximately 25 years ago, we systematically searched the published literature from January 1, 1990, through June 23, 2014. We searched in PubMed (MEDLINE), PsycINFO, and the Cochrane Library. We reviewed the reference lists of relevant papers, and we examined any literature suggested by KIs. We will update the literature review by repeating our searches concurrent with the peer-review process. Gray Literature Search: We searched the gray literature to identify information beyond the published literature on management strategies to reduce psychiatric readmissions. Sources for the gray literature included the following: HAPI, OpenSIGLE, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Academic Search Complete, NIH RePORTER, and ERIC. We also searched Web sites of the relevant professional associations such as the American Psychiatric Association, the National Alliance on Mental Illness, the National Association of Psychiatric Health Systems, and the National Institute of Mental Health. Appendix A provides a brief description of each of these gray literature sources.
PROSPERO
N/A
DOI
10.7301/Z00P0WXT
Notes
The systematic review data of this published Technical Brief was retrospectively imported into SRDR by the RTI-UNC EPC for the Agency for Healthcare Research and Quality (AHRQ). The contents of the uploaded files include: 1) Psych Discharge SRDR Design tab_7 16 15_final_v.2 - Study designs, sample sizes, lengths of follow-up, settings, and countries in which included studies were conducted 2) Psych Discharge SRDR Arm Details tab_7 16 15_final_v.2 - Descriptions of management strategy types evaluated in each study, and intervention and comparator arms 3) Psych Discharge SRDR Outcome Details tab_7 16 15_final_v.2 - Hospital readmission outcomes reported, and qualitative summaries of each study's findings
Funding Source
The Agency for Healthcare Research and Quality (AHRQ)

Key Questions

1. Describe core components for management strategies to reduce readmissions: LOS, transition support services, short-term alternatives to hospitalization, and long-term approaches to decreasing readmission. ** a. For LOS for psychiatric hospitalizations: What are clinically meaningful categorizations of LOS; what are the advantages/disadvantages of different LOSs; how do LOSs vary by patient demographics, diagnosis, and coexisting conditions; and what are the specific harms or safety issues? ** b. For transition support services: What are the different types or modalities of transition support services proposed for or used in clinical practice; what are the advantages/disadvantages of each; how do transition support services vary by patient demographics, diagnosis, and coexisting conditions; and what are the specific harms or safety issues? ** c. For short-term alternatives to hospitalization: What are the different alternatives to psychiatric hospitalization that have been proposed or used in clinical practice; what are the advantages/disadvantages of each; how do alternatives to hospitalization vary by patient demographics, diagnosis, and coexisting conditions; and what are the specific harms or safety issues? ** For long-term approaches to reducing psychiatric readmissions: What are the different other approaches that have been proposed or used in clinical practice; what are the advantages/disadvantages of each; how do these approaches vary by patient demographics, diagnosis, and coexisting conditions; and what are the specific harms or safety issues?
2. Describe the context in which management strategies are used. ** a. How do these management strategies vary across the United States? ** b. For our primary outcome of interest: how accurate and valid are psychiatric readmissions data? What are other key secondary outcomes to consider for assessing the advantages/disadvantages of the various management strategies? ** c. What kinds of training/certification, staffing, and other resources are required to ensure optimal use of management strategies?
3. Describe current evidence about the effectiveness of these management strategies. What is the effect of each strategy on readmissions and the secondary outcomes (see Table 1)?
4. Identify important issues raised by the use of these management strategies for reducing readmissions. ** a. What are other immediate and long-term implications (such as ethical, privacy, equity, or cost considerations) of current length of psychiatric admissions, available transition support services, and alternatives to hospitalization? ** b. What gaps exist in the current evidence base on these management strategies? What are possible areas of future research?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
No Data
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An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use.2013
Assessing the outcome of compulsory treatment orders on management of psychiatric patients at 2 McGill University-associated hospitals.2012
No Data
Reducing six-month inpatient psychiatric recidivism and costs through case management.2010
No Data
Reducing 30-day inpatient psychiatric recidivism and associated costs through intensive case management.-- Not Found --
Clinical case management of revolving door patients - a semi-randomized study.2008
No Data
Extended outpatient civil commitment and treatment utilization.2006
Psychoeducation and compliance in the treatment of schizophrenia: results of the Munich Psychosis Information Project Study.
Effects of compulsory treatment orders on time to hospital readmission.2005
An evaluation of a family psychoeducation program in community mental health.2003
Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough.2002
No Data
No Data
Establishing the efficacy and cost effectiveness of community intensive case management of long-term mentally ill: a matched control group study.2000
Community treatment orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission.2000
Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals.1999
Managed care. The effect of case management on state psychiatric clients.1999
No Data
No Data
No Data
Psychoeducational multiple family groups: four-year relapse outcome in schizophrenia.1995
Service utilization and costs of care for severely mentally ill clients in an intensive case management program.1995
No Data
Community psychiatric nurse teams: intensive support versus generic care.1994
The effect of intensive case management on hospitalization of patients with schizophrenia.1993
No Data
No Data
No Data
No Data
No Data
No Data
Cost-effectiveness analysis of case management versus a routine community care organization for patients with chronic schizophrenia.2000
No Data
Collaborative care for bipolar disorder: Part II. Impact on clinical outcome, function, and costs.
Practices preventing rehospitalization of individuals with schizophrenia.2006
Effectiveness of a high end users program for persons with psychiatric disorders.2012
No Data
Outpatient commitment for "revolving door" patients: compliance and treatment.1991
Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina.1990
Intensive versus standard case management for severe psychotic illness: a randomised trial. UK 700 Group.1999
Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations.2011
Operation outreach: intensive case management for severely psychiatrically disabled adults.1990
A pilot investigation of the relationship between community treatment orders and hospital utilization rates.2010
The long-term effect of outpatient commitment on service use.2000
The efficacy of involuntary outpatient treatment in Massachusetts.1998
The effectiveness of outpatient civil commitment.1996
Community treatment orders: profile of a Canadian experience.2005
Involuntary outpatient commitment: a naturalistic study of its use and a consumer survey at one community mental health center in Israel.2005
Assessing outcomes for consumers in New York's assisted outpatient treatment program.2010
No Data
Use of community treatment orders to prevent psychiatric hospitalization.2008
The effectiveness and ethical justification of psychiatric outpatient commitment.2007
No DataNo Data
Not Found - Please check PubMed ID for accuracy.
The effectiveness of community support programs in rural Minnesota: A ten year longitudinal study2000
Case Management in a Psychiatric Hospital: Review of Outcomes and Resource Utilisation2006
Intensive case management for frequent users of psychiatric hospitals in a large city: A comparison of team and individual caseloads1991
Findings from a consumer/survivor defined alternative to psychiatric hospitalization2002
Comparison of Service Outcomes of Case Management Teams With and Without a Consumer Provider2008
Case Management in a Psychiatric Hospital: Review of Outcomes and Resource Utilisation2006
The utility of extended outpatient civil commitment.-- Not Found --
Findings from a consumer/survivor defined alternative to psychiatric hospitalization2002
Implementing assertive community treatment teams1995
Intensive case management for frequent users of psychiatric hospitals in a large city: A comparison of team and individual caseloads1991
Assertive community treatment for persons with severe mental disorders: A controlled treatment outcome study
Involuntary Outpatient Commitment in Florida: Case Information and Provider Experience and Opinions2009
Comparison of Service Outcomes of Case Management Teams With and Without a Consumer Provider.2008
Assertive community treatment for persons with severe mental disorders: A controlled treatment outcome study1999

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