Helping Patients with Mental Illness Engage in Their Transitional Care [Internet]

Excerpt

Background: As many as 40% of individuals with behavioral health challenges (BHCs) that require hospitalization—such as psychotic disorders, affective disorders, and severe anxiety disorders—do not attend any outpatient visits in the 30 days following discharge.

Objectives: We examined engagement-focused care (EFC) vs treatment as usual (TAU) in a university-based transitional care clinic (TCC) with a 90-day program serving individuals with BHCs who were discharged from hospitals and emergency departments (EDs). EFC included a unique group intake process, designed to get individuals into care rapidly, and a coach for shared decision-making (SDM).

Methods: We approached individuals for study either before hospital discharge or upon arrival to the TCC, following referral. Assessments of quality of life (QOL), symptomatology, and SDM preferences were conducted at an initial assessment, at 3 months (corresponding to the end of TCC treatment), and 6 months post-TCC discharge. We assessed communication among participants and providers at each TCC visit and we assessed service utilization during and post-TCC for inpatient, outpatient, emergency, and hospital services as well as in criminal justice contexts.

Results: For the primary outcome—ie, subjective QOL from the Quality of Life Interview—465 patients were randomized, 326 completed an initial assessment, 274 were lost to follow-up (139 of these never even received an initial assessment), and 191 had an initial and at least 1 follow-up assessment and were included in the primary repeated measures analysis of covariance for mixed models. Mean subjective QOL scores were 3.88 (95% CI, 3.73-4.02) and 3.78 (95% CI, 3.56-4.00) for EFC and TAU, respectively, at initial assessment; 4.33 (95% CI, 4.14-4.52) and 4.04 (95% CI, 3.78-4.29) at 3 months; and 4.48 (95% CI, 4.26-4.70) and 4.19 (95% CI, 3.93-4.45) at 6 months. The mixed effects regression, examining impact on subjective QOL, yielded significant effects of group (ie, EFC vs TAU) at 3 months (F_1,216 = 4.14; P = .04); and nonsignificant effects of time (F_1,132 = 2.31; P = .13) and group by time (F_1,132 = 0.32; P = .56). The effect size for the group effect was 0.28 (Cohen d), which is a small effect. The views of prescribers and consumers about communication converged as time went on, and 91% of patients wanted at least some say in decisions about their treatment.

Conclusions: EFC, an intervention consisting of 2 components—access to a group intake and access to an SDM coach—may improve QOL. Most people with BHCs want some say in treatment decisions.

Limitations: We conducted the study at only one site, many individuals were lost to follow-up, and due to the nature of our clinic, we conducted the first assessment following randomization. Our TAU was likely superior to the typical standard care in the community, reducing the ability to find group differences between EFC and TAU.