A RCT feasibility study of a Transitional Care Model that integrates physical and mental health care for individuals discharged from a psychiatric hospitalization

Research objective: Few models exist that address the need for integrated medical and mental health care in the SMI population, although they have multi-morbid states associated with high cost of care and die 25 years earlier than the general population from treatable health conditions. Present study tests feasibility and preliminary effectiveness of a modified transitional care model (TCM) (an EBP for medically ill older adults transitioning from hospital to home) for persons with severe mental illness (SMI) and medical co-morbidity being released from an acute care psychiatric inpatient unit.

Research Methods: RCT of 40 subjects 18-65 with SMI and comorbid major medical illnesses were recruited from two psychiatric inpatient units. Twenty received TAU plus TCM from a psychiatric nurse practitioner for 90 days following hospital discharge and 20 received TAU. Outcome measures included readmission, emergency room use, medication adherence, links with community providers, and psychosocial functioning and mental health /health status measures.

Findings: No statistically significant differences. However, barriers to intervention implementation were the interaction of psychosocial and health/mental health status of the patient and the lack of shared health care information and collaboration with the nurse from the communitywide health care system.

Lessons Learned: • Unstable housing and substance abuse were major barriers to improved health/mental health status • Surveillance by a nurse likely resulted in increased hospital use • Team lacked a social worker and a peer to address psychosocial needs and patient engagement in intervention • Lack of system cooperation resulted in barriers to delivery of intervention