Nancy P. Hanrahan, PhD, RN, FAAN Dr. L. Kurlowicz Memorial Term Chair
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Lessons learned from a pilot RCT to test the effect of a Transitional
Care Model for improving post hospital outcomes for individuals
with serious mental illness
Nancy P. Hanrahan, PhD, RN, FAANDr. L. Kurlowicz Memorial Term Chair
Associate Professor Psychiatric Mental Health Nursing Center for Health Outcomes and Policy Research
University of Pennsylvania School of Nursing
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Investigators & Funding
Funded by Robert Wood Johnson Nurse Inquiry program for 18 months
Co-PI – Phyllis Solomon, Ph.D. Professor, School of Social Policy & Practice, University of Pennsylvania
Co- Investigator: Matthew Hurford, M.D. Assistant Professor, Dept of Psychiatry, University of Pennsylvania
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Disclosures
No Disclosures to report
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Need for Innovative Models of Care
Chronic illnesses cause disability and death for 133 Million Americans1
• 78% of the total U.S. health care spending goes to treat chronic illness
Serious Mental Illness (SMI) + medical comorbidities are highest need and highest cost. 2-3
• 15 million Americans• Top 5% of Medicaid spending• Annual per person costs of $43,130-$80,374.
1. Institute of Medicine. Living Well with Chronic Illness: A Call for Public Health Action. Washington,DC: The National Academies Press; 2012.
2. Kronick RG, Bella M, Gilmer TP. The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions. Washington, D.C.: Center for Health Care Strategies;2009.3. Coughlin TA, Waidmann TA, Phadera L. Among Dual Eligibles, Identifying The Highest-Cost Individuals Could Help In Crafting More Targeted And Effective Responses. Health Affairs. May 1, 2012 2012;31(5):1083-1091.
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Despite this level of investment....
Poor health of SMI is striking Die 25 years earlier than the general
population from treatable illnesses4-5
• 3.4 x die from heart disease of diabetes• 3.8 x die from accidents• 5.0 x die from respiratory ailments• 6.6 x die from pneumonia influenza• 3.8 x die from HIV
4.Colton CW, Mandersheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prevention of Chronic Disease [serial online]. 2006; http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm. Accessed 11/25, 2008.5. Hardy S, Thomas B. Mental and physical health comordibity: Political imperatives and practice implications. International Journal of Mental Health Nursing. 2012;21(3):289-298.
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Factors related to poor quality health care for SMI
Patient Factors Provider Factors
System Factors
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Patient contributors to poor health
• MH problems lead to inability to navigate health system – amotivation, cognitive deficits, & poor health literacy
• 80% impoverished• Poor nutrition• Unstable housing• High use of tobacco, drug & alcohol use• Lack of exercise• Sedentary life style• Psychotropic meds contribute to health risk
factors: weight gain, insulin resistance & elevated blood glucose & lipids
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Provider contributors to poor health High incidence of untreated hypertension, elevated blood
sugar, high cholesterol, & asthma Poor routine preventive services Poor quality medical care contributor to excess morbidity &
mortality MH clinicians lack of knowledge & comfort with medical
issues MH clinicians lack of time & resources to deal with medical
issues Primary care providers lack of knowledge & comfort with
SMI population Clinical demands of primary care providers make it difficult
in dealing with co-morbidities When SMI receive medical care, generally do not receive
care that meets clinical guidelines
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System Contributors to Poor Health
MH facilities do not provide medical care due to financing challenges & lack of expertise
Fragmentation of systems – health, mental health, & substance abuse silos of c are
Complexity of MH & Health systems – different financing & policies – don’t communicate with each other
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Consequently
Lack of coordinated care across systems
High use of hospitals & ED – very costly
Increasing recognition of need for integration of medical & behavioral health care
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Transitional Care Model
Transitional Care Model (TCM)- an EBP medically ill elderly (Naylor, 1999, 2000, 2004)
TCM – uses advance practice nurse to manage care of high risk clients from hospital to home
20 years of study show significant improvements in outcomes & reduced costs for high risk clients, particularly with chronic illnesses
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TCM and SMI
TCM limited examination for patients with SMI Although evidence of costly cycling in & out of
hospital during exacerbation of illness of those with SMI
High cost of hospitalization in period of shrinking health care resources
Likely preventable rehospitalizations Discharge from hospital opportune time to
intervene for patients with co-morbid medical problems
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Research Questions
Purpose of study – to answer following questions:• Does TCM compared to usual care improve
hospital to home outcomes (eg. Reduced rehosp. & ED use, & increase links to community mental health) for discharged patients with SMI and medical comorbidities?
• Is it feasible to implement & modify TCM for discharged patients with SMI?
• What are the barriers & facilitators to implementing & sustaining this model?
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Methods
Pilot RCT Control Group (n=20) treatment as usual (case
management provided by CMHAs) Experimental group (n=20) Psychiatric Nurse
Practitioner intervention, met with patient prior to discharge, met immediately after discharge, home visits, ongoing phone calls, accompany to medical & mental health appointments, contact medical & mental health providers, medication management, last 3 months
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Methods
Eligibility criteria:• 18-65• SMI – schiz, bipolar, & major affective disorders• Major medical problem, diabetes,
cardiovascular problems, cancer, etc. Recruitment: 2 inpatient psychiatric units
from general hospital in Philadelphia• RA sat in on daily team meetings (psychiatrist,
residents, nurses & discharge social worker) to screen for eligible patients for study
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Methods
Outcomes• Medical & psychiatric readmissions• Emergency room use• Links to community mental health
providers Analysis
• Formal statistical tests not conducted due to small sample size
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Sample Characteristics
Sample Characteristic Control (N=20) Intervention (N=20)
Age mean, SD 45.8 ,SD=11.9 44.1, SD=11.2
Income (past month) 711.2, SD=430.1 716.6, SD=458.4
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Sample CharacteristicsControl (n=20)
Intervention (n=20)
N % N %
GENDER Male 10 50 11 55
RACE AA 9 45 9 45
WhiteOther
74
3520
65
3025
ETHNICITY Hisp/Latino 2 10 1 5
MARITAL STATUS
SingleMarriedDivorcedSeparatedWidowed
153200
75151000
123221
601510105
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Sample CharacteristicsControl (n=20)
Intervention(n=20)
Education Less than HS11 55 8 40
HS 4 20 6 30
Post HS tech2 10 0 0
Some college2 10 5 23
College Grad 1 5 0 0
EmployedSome Grad.Yes
02
010
13
515
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Sample Characteristics
Current Living Situation ControlN=20
InterventionN=20
N % N %
Home, hotel, apartment
With family
With friends
Emergency Shelter
Halfway House, Board & care
No regular place to live
12
1
1
3
2
1
60
5
5
15
10
5
12
3
0
2
1
2
60
15
0
10
5
10
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Psychiatric Diagnoses
Diagnosis Control(n=20)
Intervention (n=20)
N % N %
Mood 8 40 9 45
Major Depressive Disorder 5 25 5 25
Bipolar Disorder 10 2 10
Depression, NOS 1 5 2 10
Psychosis 12 60 11
55
Schizophrenia Schizoaffective Disorder Psychosis, NOS
26
4
103020
560
2530 0
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Medical Comorbidities
Medical Diagnosis ControlN=20
InterventionN=20
N % N %
Cardiovascular DiseaseRespiratory IllnessNeurological Disorders: seizureGastro-Intestinal: GERDEndocrine: DiabetesCancerHIVHepatitis CHepatitis B
14 8 3 5 7 3 3 2 0
7040152535151510 0
12 7 6 311 0 0 2 1
6035301555 0 010 5
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Psychiatric & Medical Comorbidities
Statistic Control
Intervention
Psychiatric Medical Psychiatric Medical
Mean 0.7 3.65 0.5 2.5
Min 0.0 1.0 0.0 1.0
Max 3.0 7.0 2.0 6.0
SD 0.92 1.68 0.69 2.3
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Successful Case Example Hx – Female hosp. for manic episode; Bipolar, hypertension,
non-insulin dep. Diabetes, rectal cancer, seizure disorder Barriers – overwhelmed with medical problems, appts, primary
support finance with active substance abuse problem Facilitators – motivated to get well, providers appreciated APN APN Intervention – ed. On med. Dx & medications, coor.
prescription refills, recommendations of medication with primary care physician, accompanied to medical & psychiatric appts, coor. Hosp. admission for chemo with other appts
Outcome – successfully completed medical tx for rectal cancer, reconnected with Primary care physician & outpatient psychiaty and no psychiatric rehops.
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Unsuccessful Case Example Hx – 49 yrs Caucasian male; admitted for being physically
aggressive & pushing boarding home staff member; Schiz paranoid; traumatic brain injury & seizure disorder
Barriers – cognitive impairment & thought disorder – difficulty communicating; Boarding home unlicensed & eventually shut down
Facilitators – initially contact with ICM good – but overtime less responsive; reconnected to outpt psychiatry, primary care physician & neurologist
APN Int. – difficulty with anxiety & sleeping at Bd home – APN prescribed medication; educated staff on behavioral management; initial contact with ICM
Outcome – readmitted to hosp. after going to new residence & reporting suicidal ideation to psychiatrist- very aggressive while in hosp.; discharged from hosp. but returned same day - remained hosp. until end of intervention
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Results: Service Utilization
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Links with Community Following Index Hospitalization
Table 3.0 Links with Community following Index Hospitalization
Intervention Control P value
n % n %
Any Appointment at Discharge
16 80.0% 19 95.0% .151
Attended Discharge Appointments
17 85.0% 15 75.0% .720
Lost to Follow-up 2 10.0% 3 15.0% .633
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Lessons Learned
Complexity/acuity of need Conflict-ridden/highly intense
relationships Unstable housing Tracking patients HIPAA laws and confidentiality issues Cross-system Ambassador
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Recommendations T-Care is a feasible model with revisions….
• Transitional Care Team: Advanced Practice Psychiatric Nurse Practitioner, Professional Social Worker, and Peer Support
• Integrated care approach with nurse as Ambassador• Recruit from both medical and psychiatric settings• Measures: add care coordination, longitudinal clinical
and cost measures up to two years• HIPAA implementation reform• Clinical data integration• Integrate Transitional Care Model into the system.