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Lessons learned from a pilot RCT to test the effect of a Transitional Care Model for improving post hospital outcomes for individuals with serious mental illness. Nancy P. Hanrahan, PhD, RN, FAAN Dr. L. Kurlowicz Memorial Term Chair Associate Professor Psychiatric Mental Health Nursing
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Lessons learned from a pilot RCT to test the effect of a Transitional Care Model for improving post hospital outcomes for individuals with serious mental illness Nancy P. Hanrahan, PhD, RN, FAAN Dr. L. Kurlowicz Memorial Term Chair Associate Professor Psychiatric Mental Health Nursing Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing
Investigators & Funding Funded by Robert Wood Johnson Nurse Inquiry program for 18 months Co-PI – Phyllis Solomon, Ph.D. Professor, School of Social Policy & Practice, University of Pennsylvania Co- Investigator: Matthew Hurford, M.D. Assistant Professor, Dept of Psychiatry, University of Pennsylvania
Disclosures No Disclosures to report
Need for Innovative Models of Care Institute of Medicine. Living Well with Chronic Illness: A Call for Public Health Action. Washington,DC: The National Academies Press; 2012. 2.KronickRG, Bella M, Gilmer TP. The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions. Washington, D.C.: Center for Health Care Strategies;2009. 3.Coughlin TA, Waidmann TA, Phadera L. Among Dual Eligibles, Identifying The Highest-Cost Individuals Could Help In Crafting More Targeted And Effective Responses. Health Affairs. May 1, 2012 2012;31(5):1083-1091. • Chronic illnesses cause disability and death for 133 Million Americans1 • 78% of the total U.S. health care spending goes to treat chronic illness • Serious Mental Illness (SMI) + medical comorbidities are highest need and highest cost. 2-3 • 15 million Americans • Top 5% of Medicaid spending • Annual per person costs of $43,130-$80,374.
Despite this level of investment.... 4.Colton CW, Mandersheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prevention of Chronic Disease [serial online]. 2006; http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm. Accessed 11/25, 2008. 5.Hardy S, Thomas B. Mental and physical health comordibity: Political imperatives and practice implications. International Journal of Mental Health Nursing. 2012;21(3):289-298. • Poor health of SMI is striking • Die 25 years earlier than the general population from treatable illnesses4-5 • 3.4 x die from heart disease of diabetes • 3.8 x die from accidents • 5.0 x die from respiratory ailments • 6.6 x die from pneumonia influenza • 3.8 x die from HIV
Factors related to poor quality health care for SMI Patient Factors Provider Factors System Factors
Patient contributors to poor health • MH problems lead to inability to navigate health system – amotivation, cognitive deficits, & poor health literacy • 80% impoverished • Poor nutrition • Unstable housing • High use of tobacco, drug & alcohol use • Lack of exercise • Sedentary life style • Psychotropic meds contribute to health risk factors: weight gain, insulin resistance & elevated blood glucose & lipids
Provider contributors to poor health High incidence of untreated hypertension, elevated blood sugar, high cholesterol, & asthma Poor routine preventive services Poor quality medical care contributor to excess morbidity & mortality MH clinicians lack of knowledge & comfort with medical issues MH clinicians lack of time & resources to deal with medical issues Primary care providers lack of knowledge & comfort with SMI population Clinical demands of primary care providers make it difficult in dealing with co-morbidities When SMI receive medical care, generally do not receive care that meets clinical guidelines
System Contributors to Poor Health • MH facilities do not provide medical care due to financing challenges & lack of expertise • Fragmentation of systems – health, mental health, & substance abuse silos of c are • Complexity of MH & Health systems – different financing & policies – don’t communicate with each other
Consequently Lack of coordinated care across systems High use of hospitals & ED – very costly Increasing recognition of need for integration of medical & behavioral health care
Transitional Care Model Transitional Care Model (TCM)- an EBP medically ill elderly (Naylor, 1999, 2000, 2004) TCM – uses advance practice nurse to manage care of high risk clients from hospital to home 20 years of study show significant improvements in outcomes & reduced costs for high risk clients, particularly with chronic illnesses
TCM and SMI 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
Research Questions • Purpose of study – to answer following questions: • Does TCM compared to usual care improve hospital to home outcomes (eg. Reduced rehosp. & ED use, & increase links to community mental health) for discharged patients with SMI and medical comorbidities? • Is it feasible to implement & modify TCM for discharged patients with SMI? • What are the barriers & facilitators to implementing & sustaining this model?
Methods Pilot RCT 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, last 3 months
Methods • Eligibility criteria: • 18-65 • SMI – schiz, bipolar, & major affective disorders • Major medical problem, diabetes, cardiovascular problems, cancer, etc. • Recruitment: 2 inpatient psychiatric units from 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 • Medical & psychiatric readmissions • Emergency room use • Links to community mental health providers • Analysis • Formal statistical tests not conducted due to small sample size
Successful Case Example Hx – Female hosp. for manic episode; Bipolar, hypertension, non-insulin dep. Diabetes, rectal cancer, seizure disorder Barriers – overwhelmed with medical problems, appts, primary support finance 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 psychiaty and no psychiatric rehops.
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 – initially contact with ICM good – but overtime less responsive; reconnected to outpt psychiatry, primary care physician & neurologist APN Int. – difficulty with anxiety & sleeping at Bd 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
Lessons Learned Complexity/acuity of need Conflict-ridden/highly intense relationships Unstable housing Tracking patients HIPAA laws and confidentiality issues Cross-system Ambassador
Recommendations • T-Care is a feasible model with revisions…. • Transitional Care Team: Advanced Practice Psychiatric Nurse Practitioner, Professional Social Worker, and Peer Support • Integrated care approach with nurse as Ambassador • Recruit from both medical and psychiatric settings • Measures: add care coordination, longitudinal clinical and cost measures up to two years • HIPAA implementation reform • Clinical data integration • Integrate Transitional Care Model into the system.
