1. 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)

2. 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

3. 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

4. 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

5. 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

6. 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%

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

9. 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)

10. 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

11. 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

12. 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)

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

14. 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

15. 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)

16. 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)

17. 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 % (2011)

18. 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%

19. 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)

20. 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

21. 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)

22. 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)

23. 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)

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

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