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)

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

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

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

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

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

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

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)

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

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 Patient’s Living Conditions after Discharge Residential Instability or Homelessness Living with Parents Need for Relief from Caregiving Responsibilities

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)

Strategies to Reduce Readmission Medication Practices Engagement in Outpatient Services Inpatient Clinical Interventions

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

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)

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)

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)

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%

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)

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

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)

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)

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)

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

Acknowledgements Report Co-Authors: Charles Begley, Ph.D.(Postdoctoral Co-mentor @ 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