30-Day Psychiatric Readmissions: Rates, Reasons, Responses

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30-Day Psychiatric Readmissions Rates, Reasons,
Responses

• Jane Hamilton, Ph.D.
• Postdoctoral Research Fellow
• The University of Texas Medical School at Houston
• Department of Psychiatry and Behavioral Sciences
• Harris County Psychiatric Center (HCPC)

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Why Examine 30-Day Psychiatric Readmissions?

• Health care reform established the goal of
  reducing 30-day readmissions across medical
  conditions
• Increased interest in 30-day psychiatric
  readmission rates as quality indicators
• Internationally accepted indicator of the quality
  of inpatient care as well as the transition to
  community-based care after discharge

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Report Objectives

• Review peer-reviewed articles for rates,
  determinants, and strategies for reducing 30-day
  psychiatric readmissions
• Synthesize evidence into a behavioral health
  report that will be disseminated to the Houston
  community

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Review Methods

• Electronic searches of MEDLINE and PubMed
• Follow-up searches of cited articles
• Google searches for rates and best practices
• Examination of bests practice interventions
  implemented in other states
• Key Words Hospitals, Psychiatric, Patient
  Readmission, Rehospitalization, Interventions,
  Reduction, 30-Day

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Inclusion/Exclusion Criteria

• Inclusion Original research and systematic
  reviews (published from 1996 to 2014) examining
  predictors of psychiatric readmission and/or
  interventions to reduce psychiatric readmission
• Exclusion Studies examining readmissions in
  acute care hospitals, involving children and
  adolescents, in languages other than English

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Rates of Readmission
Population Region Year 30-Day Readmission Rate
Medicaid Patients (Overall) U.S. 2007 10.7
Medicaid Patients (Mental Health Diagnosis) U.S. 2007 11.8
Medicaid Patients (Substance Abuse Diagnosis) U.S. 2007 13.0
Medicare Psychiatric Patients U.S. 2007 15.0
Psychiatric Hospital Patients (Excluding State Hospitals) Texas 2012 11.2
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Demographic Factors

• Male Gender
• Young Age
• Divorced or Unmarried
• Unemployed
• Low-income or Receiving Public Assistance

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Clinical Factors

• Diagnosis of a Psychotic Illness
• Substance Abuse and/or Dependence
• Co-occurring Personality Disorders
• Suicidal Ideation, Suicide Plans, or Suicide Risk
  
• Patient Severity (measured by psychometric scales
  or by clinician assessment)

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Treatment Factors

• Number of Previous Psychiatric Hospitalizations
• Shown across studies to be a reliable predictor
• Medication Non-Adherence After Discharge
• 7 studies found a significant relationship
• Length of Stay (LOS) During the Previous
  Admission
• The effect of LOS has been inconsistent across
  studies
• Longer LOS may reflect patient severity

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Community Factors

• Aftercare and Follow-up Arrangements
• No Scheduled Aftercare Appointment
• Not Having the Discharge Plan Sent to Aftercare
  Providers
• Limited Contact with Aftercare Providers
• Patients Living Conditions after Discharge
• Residential Instability or Homelessness
• Living with Parents
• Need for Relief from Caregiving Responsibilities

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Readmission Risk Factor Clusters

• Young males diagnosed with Schizophrenia with
  prior hospitalizations (Appleby et al., 1993
  1996)
• Patients diagnosed with Major Depressive Disorder
  with co-occurring substance abuse and/or
  personality disorders (Lin et al., 2007)
• Patient-reported anxiety symptoms, elevated
  depression scores, and the number of previous
  hospitalizations (Averill et al., 2001)

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Strategies to Reduce Readmission

• Medication Practices
• Engagement in Outpatient Services
• Inpatient Clinical Interventions

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Long-Acting Injectables Depot Medications

• Used to Treat Patients with Schizophrenia and
  Other Psychotic Disorders
• Provides More Predictable and Stable Serum
  Concentrations of the Active Drug
• May Improve Overall Rates of Treatment Adherence
• May Improve Early Detection and Prevention of
  Relapse
• May Reduce Readmission Rates

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Clozapine

• Gold Standard Treatment for Schizophrenia
• Underutilized - only used with 10-20 of patients
  with approved indications (Meltzer, 2012)
• Primary indications
• Treatment-resistant Schizophrenia or
  Schizoaffective Disorder
• Patients with Schizophrenia or Schizoaffective
  Disorder who are at high risk for suicide
• Safety concerns may cause underutilization
• Increased awareness of risks and benefits
  recommended
• Hospital-based study found discharged patients
  who received Clozapine were less likely to be
  readmitted (Essock et al., 1996)

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Medication Best Practices

• Medication Reconciliation Process of comparing a
  patient's medication orders to all of the
  medications that the patient has been taking
• To avoid medication errors such as omissions,
  duplications, dosing errors, or drug interactions
• Done at every care transition
• Multiple members of the treatment team should
  participate
• Medication Fill and Counseling at Discharge
• A recent study found that discharged patients
  provided with filled psychiatric prescriptions
  and medication counseling from the pharmacist
  were significantly less likely to be readmitted
  (Tomko et al., 2013)

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Outpatient Engagement Quarterly Data Sharing and
Case Reviews

• State-wide program implemented by Amerigroup
  Florida to improve the transition to outpatient
  care and reduce readmissions
• 7 psychiatric hospitals with high readmission
  rates and costs participated
• Strategies included
• Quarterly meetings to review admissions and LOS
  data
• Case reviews
• Facilitation of appropriate treatment and support
  services after discharge
• Readmissions reduced from 17.7 (2008 ) to 10.4
  -10.9 (2011)

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Transitional Care Model

• Pilot intervention designed to improve
  communication between settings and increase
  patient and family effectiveness in navigating
  the health care system (Batscha et al., 2011)
• Intervention components
• Pre-discharge transition interview
• Appointment reminder letter
• Brief meeting at the first post-discharge
  appointment
• Twelve (92) of 13 patients attended the
  post-discharge appointment compared with the
  previous rate of 44

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Assertive Community Treatment

• Evidence-based practice model (developed in 1980,
  extensively evaluated)
• Multidisciplinary team provides treatment,
  rehabilitation, and support services for
  individuals with severe mental illness
• High fidelity models found to reduce
  hospitalization by 58 compared to case
  management interventions (Latimer, 1999)
• 1.4 of clients served within the Texas mental
  health system participated in 2012 (SAMHSA, 2012)

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Intensive Case Management (ICM)

• A Retrospective study of 164 clients found ICM
  was associated with fewer readmissions and longer
  community tenure compared to case management
  (Kuno et al., 1999)
• A Cochrane Review (2010) reported that ICM
  reduced hospitalizations and increased engagement
  in outpatient care compared to treatment as
  usual, particularly for individuals with multiple
  readmissions

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Assisted Outpatient Treatment (AOT)

• Court-ordered program designed to improve
  outcomes for persons
• With serious mental illness
• Multiple psychiatric hospitalizations
• Non-adherence with outpatient care
• An AOT evaluation found that a substantial
  investment of state resources was required
  upfront, but it reduced the overall service costs
  for persons with serious mental illness (Swanson
  et al., 2013)
• Participation in AOT associated with
• Reduced LOS
• Increased receipt of services (medication and
  ICM)
• Greater engagement in outpatient services (Swartz
  et al., 2010)

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Peer to Peer Services

• Clients randomized to a peer mentorship program
  had significantly fewer readmissions and fewer
  hospital days than those in usual care at 9-month
  follow-up post-discharge (Sledge et al., 2011)
• A longitudinal comparison of clients with
  co-occurring substance use disorders and mental
  illness found those who participated in a peer
  support program had higher community tenure and
  lower readmissions than clients in a comparison
  group (Min, 2007)

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Other Clinical Interventions

• Motivational Interviewing (MI)
• Randomized trial of 121 psychiatric inpatients
  found that adding a 1-hour MI session prior to
  discharge was associated with attendance at the
  first outpatient appointment compared to
  treatment as usual (Swanson, 1999)
• Cognitive Behavioral Therapy (CBT)
• Manualized CBT group therapy was introduced on an
  inpatient unit and was associated with
  significant reductions in readmissions (from 38
  to 24) for patients with schizophrenia and
  bipolar disorder (Veltro, 2008)

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Discussion

• Please share your successes/challenges with any
  of the strategies presented today.
• Thank you!

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Acknowledgements

• Report Co-Authors
• Charles Begley, Ph.D.(Postdoctoral Co-mentor _at_
  UTSPH)
• Juan Galvez, M.D. (UT Psychiatry Postdoctoral
  Research Fellow)
• Sponsor
• Jair Soares, M.D., Ph.D. (Postdoctoral Mentor)
• Department Chair, UT Medical School Department of
  Psychiatry and Behavioral Sciences Executive
  Director of Harris County Psychiatric Center