Abstract
As the demand for mental health care increases, acute care settings like emergency departments and inpatient psychiatric units have become overburdened. Intermediate levels of care and alternate treatment pathways are understudied and could efficiently utilize existing resources while also improving patient outcomes. This scoping review aims to identify common factors influencing community healthcare utilization to inform future research and development of novel or hybrid interventions.
Ovid MEDLINE(R) (1946 to Present) was searched within Mayo Clinic libraries and a total of 36 articles were included: 3 clinical trials, 1 computer simulation, 1 cross sectional study, 2 meta-analyses, 5 observational studies, 1 prospective cohort study, 5 quasi-experimental studies, 9 randomized control trials, 6 retrospective cohort studies, and 3 review articles.
Several factors impacting rates of emergency department visits and inpatient hospital admissions for individuals with severe mental illness were identified. Access to specialized psychiatric care often within primary care settings allows for efficient triage into most appropriate treatment pathway. At the level of the healthcare-system hospital self-referral programs (SRIT), transitional discharge models (TDM), and home-based treatments have preliminary revealed promising results. Structured community-based programs like Assertive Community Treatment (ACT), Flexible Assertive Community Treatment (FACT), Community Based Mobile Crisis Services (CBMCS) and Crisis Response Teams (CRT) have been associated with reduced utilization and improved patient outcomes. Individual factors include patient autonomy, improved communication, opportunities for community engagement and inclusion of family / support system.
There is not a “one-size-fits-all” approach but multiple, evidence-based pathways capable of increasing the likelihood of optimal patient outcomes and improved stewardship of community resources. Integrating aspects of these programs into hybrid models may prove beneficial for certain patient populations which should be explored as part of future research studies.
Keywords
Severe and persistent mental illness, Healthcare utilization, Community mental health services, Hospital admissions, Emergency department visits
Introduction
The demand for mental health care continues to rise at disproportionate rates compared to available community resources [1]. Wait-lists to establish care with a psychiatrist can be several months and primary doctors are often ill-equipped to comfortably manage complex psychiatric conditions and psychotropic medication regimens [2]. When psychiatric symptoms are acute, few options widely exists outside of emergency departments which are already over utilized [3]. Patients are often boarded awaiting admission to the next available hospital bed or discharged after stabilization back to insufficient outpatient care [4,5]. Unfortunately, this cycle further exacerbating emergency room overutilization and repeat hospital admissions [6]. The over utilization of these resources indirectly reduces access for other patients and exacerbates existing financial inefficiencies [7]. Establishing intermediate levels of care and alternate treatment pathways could improve the efficiency of utilizing existing resources while also improving patient outcomes; however, distinct treatment pathways remain understudied and largely unavailable in most communities [1]. This scoping review aims to review potential alternative treatment pathways and identify common factors influencing community mental healthcare utilization. The results will help to inform future research and the possible development of novel or hybrid interventions.
Materials & Methods
A literature review was performed with the assistance of a trained medical healthcare librarian within the Mayo clinic library system. Ovid MEDLINE(R) (1946 to Present) was searched using the following search terms: Mental Disorders, Community Mental Health Services, Community, Hospitalization, Emergency Service, Hospital, and (access* or utiliz* or admission* or admit* or readmis* or readmit* or rehospitaliz* or revisit* or community or outpatient*) and "severe". A total of 45 articles were identified and reviewed by two independent reviewers (JB & MH). Articles considered out-of-scope, duplicates, articles not written in English and editorial or opinion articles were excluded. A total of 36 articles were included after reviewing process which are summarized in Table 1. Included are 3 clinical trials, 1 computer simulation, 1 cross sectional study, 2 meta-analyses, 5 observational studies, 1 perspective guard study, 5 quasi-experimental studies, 9 randomized control trials, 6 retrospective cohort studies, and 3 review articles.
|
Author Year |
Country |
Design |
Population |
Title |
Objective |
Methods |
Results |
Conclusions |
|
|
Puntis et al., 2016 |
England |
Prospective Cohort |
Individuals with severe mental illness (N=323) discharged from hospital following |
The association between continuity of care and readmission to hospital in patients with severe psychosis |
Investigate the relationship between continuity of care and rehospitalization in a patient population at high-risk |
As part of the Oxford Community Treatment Order Trial (OCTET) medical record data were collected on service use and eight operationalized measures of continuity of care over 36 months. Regression analyses were used to examine the relationship between continuity measures (contact with community psychiatric nurse, psychiatrist, social worker, etc.) and outcomes such as readmission, time to readmission, and hospital days. |
Patients averaged 2.9 face-to-face contacts per month, and 63.8% of patients were readmitted. More frequent contact was linked to increased odds of rehospitalization and more days hospitalized. A higher proportion of clinical correspondence (providing copies of clinical information) was linked to fewer hospital days. More changes in care coordinators were associated with more hospital days. |
Frequent and consistent patient contact may reflect illness severity rather than quality of care. Continuity of care is a multidimensional construct and a key quality indicator in health policy. Evidence linking continuity of care with positive outcomes in mental health is limited and inconsistent. |
|
|
Forchuck et al., 2005 |
Canada |
Randomized Controlled Trial |
Individuals (N=390) with severe mental illness discharged from four hospital sites in Southern Ontario |
Therapeutic relationships: from psychiatric hospital to community |
Determine the cost and effectiveness of a transitional discharge |
Participants were divided into TDM (N=201) and control (N=189) groups. TDM involved continued care from in-patient staff until community care relationships were established, and included a peer support model. Assessments took place at the point of discharge, and 1-month, 6-months, and 1 year post-discharge. T-tests were used to test the hypotheses comparing intervention and control groups. |
TDM was not associated with lower post-discharge costs and improved quality of life compared with the control group. Although not predicted a priori, intervention subjects were discharged an average of 116 days earlier per person. |
Health system research has multiple challenges especially when interventions cannot be rigorously controlled. Future studies with better measurements are needed to provide additional support for the TDM model |
|
|
Storm, 2019 |
Belgium, Norway, USA, Canada, Finland, Israel, and Iran |
Review |
Adults (aged >18 years) with serious mental illness (SMI) across 16 studies including randomized controlled trials, prospective interview study, descriptive analysis, clinical trials, and posttest-only design |
Coordinating Mental Health Services for People with Serious Mental Illness: A Scoping Review of Transitions from Psychiatric Hospital to Community |
Review challenges to coordination between care settings for people with SMI and identify improvement strategies |
Articles were independently reviewed and selected based on descriptive aspects, methodological quality and risk for bias. Both perceived challenges and improvement strategies to care coordination were identified. |
The major challenges identified were adjusting to the community and having access to consistent mental health treatment. Effective interventions improved continuity of care with established providers, provided resources for patients and caregivers, incorporated shared decision-making, and assisted with medication management. |
Effective care coordination for individuals with SMI can reduce hospitalization, improve medication adherence, and improve social functioning and quality of life. |
|
|
Puschner et al., 2011 |
Germany |
Randomized Controlled Trial |
Individuals with severe mental illness (N = 491) with history of high utilization of psychiatric inpatient care |
Needs-oriented discharge planning for high utilisers of psychiatric services: multicentre randomised controlled trial |
Examine effect of needs-orientated discharge planning on rates of psychiatric readmission, length of stay, outpatient service use, and quality of life |
Participants were randomly allocated to intervention (N=241) or control (N= 250) groups. The intervention group received needs-led discharge planning and monitoring interventions at discharge and 3 months post discharge. Intention to-treat analysis was used to evaluate outcomes at 4 points over 18-month period. |
Participants in the intervention group neither exhibited lower inpatient service use nor higher number and duration of outpatient visits. Intention-to-treat analysis revealed no effect on any of the study outcomes. |
Needs-orientated discharge planning is not recommended for implementation in routine care. Alternative approaches, such as team-based community care, may be a more beneficial intervention capable of reducing healthcare resource utilization. |
|
|
Reynolds et al., 2004 |
Scotland |
Randomized Controlled Trial |
Participants (N=19) were discharged from a psychiatric inpatient facility receiving usual treatment or an experimental group receiving the transitional discharge model |
The effects of a transitional discharge model for psychiatric patients |
Investigate the transitional discharge model designed in assisting patients adjusting to community living following psychiatric hospitalization |
The experimental (N=8) received transitional discharge support from known inpatient nurses (transitional nurses) and peer support from previous service users. The control group (N=11) received treatment as usual. Data were collected at baseline and at a 5-month follow-up. Paired t-tests were used to evaluate changes in symptom severity, levels of functioning, and quality of life. Relative risk (RR) analysis was used to evaluate re-admission rates. |
Both control and the experimental groups demonstrated significant improvements in symptom severity and functional ability. The control group was more than twice as likely to be re-admitted to hospital. |
The transitional discharge model may reduce readmissions and improve psychiatric outcomes, but larger studies are needed. The findings highlight the importance of interpersonal relationships in the treatment of psychiatric patients post-discharge. |
|
|
Shi et al., 2019 |
China |
Cross-Sectional |
Adults with mental health disorders (N=7,910) psychiatrically hospitalized in all the public hospitals and healthcare centers of Pudong New Area, Shanghai, China |
Disparities in mental health care utilization among inpatients in various types of health institutions: a cross-sectional study based on EHR data in Shanghai, China |
Compare the utilization of mental health services among inpatients in various |
Health record (EHR) data between 2013 and 2016 across community health centers, secondary general hospitals, tertiary general hospitals, and specialty hospitals were evaluated. Chi-square tests and one-way ANOVA were used to assess demographics, health insurance types, and hospital resource use. Logistic regression was applied to determine factors influencing the type of health institution chosen by patients. |
Specialty psychiatric hospitals admitted more patients and treated individuals with more severe illnesses (49.73%). Community health centers admissions were more likely among older adults, males, reduced insurance coverage, increased length of stay, and reduced costs. Patients with higher insurance coverage were more likely to seek care at tertiary hospitals. |
Community mental health service utilization could be improved through greater integration of mental health with primary care, better health insurance systems, public education and reforms with a more forceful referral system |
|
|
Ginsburg & Eng, 2009 |
United States |
Observational |
The program served approximately 1,225 nursing home-eligible participants across 9 centers over a 12-month period. |
On-site mental health services for PACE (Program of All-inclusive Care for the Elderly) centers |
Investigate healthcare outcomes following the implementation of an on-site mental and behavioral health (MBH) team into an all-inclusive care program for community older adults |
The study describes the implementation of an on-site mental and behavioral health (MBH) program, which included a psychologist, a bilingual psychiatric social worker, marriage and family therapists, and part-time psychiatrists. The outcomes were measured over 4 years by tracking changes in psychiatric inpatient utilization and the percentage of enrollees receiving mental health services before and after the implementation of the MBH program. |
There was a reduction in psychiatric |
Integrating mental health services into long-term care models for older adults reduce inpatient utilization, increase access to mental health services, and improve caregiver satisfaction |
|
|
Bouchery et al., 2018 |
United States |
Retrospective Cohort |
Individuals with serious mental illness (N = 846) receiving care delivery through a whole health model and a matched comparison group (N = 2643) |
Implementing a Whole Health Model in a Community Mental Health Center: Impact on Service Utilization and Expenditures |
Investigate whether a whole health care model implemented in a community mental health center can reduce utilization of acute care services and total Medicare expenditures |
The intervention group was made up of clients receiving care through |
The whole health model was associated with significantly lower expenditures (p<0.01), fewer hospitalizations (p<0.01), fewer emergency room visits (p<0.01), and fewer office visits (p=0.04). |
This study provides evidence that whole health care models implemented in community mental health centers |
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|
Ramanuj, 2015 |
United Kingdom |
Retrospective Cohort |
Adults with severe mental illness discharged to primary care (N=98) compared to transfer to community mental health team (N= 92) |
Acute mental health service use by patients with severe mental illness after discharge to primary care in South London |
Evaluate if discharge to primary care is associated with subsequently |
The study compared mental health service use data over a two-year follow-up. The analysis included duration of acute care services (inpatient or home treatment days) and odds of re-referral to specialist mental health services |
The discharged group was significantly more stable on clinical measures. The difference in acute service use between those discharged (27.9 days/patient) and transferred (31.7 days/patient) was not significant. Of those discharged 58.2% were re-referred to specialist mental health services with 60.3% of them in crisis. Prior hospitalization significantly increased the odds of re-referral and subsequent acute care use |
There needs to be improved |
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|
Boardman et al., 1999 |
England |
Clinical Trial |
Individuals with severe mental illness (N=177) admitted to an acute ward, either attached to a community mental health center (CMHC) or not. Participants had history of psychiatric hospitalization within the past 12 months. |
North Staffordshire Community Beds Study: longitudinal evaluation of psychiatric in-patient units attached to community mental health centres |
Determine effects of CMHCs attached to acute wards on healthcare utilization, treatment compliance and patient experience outcomes |
There were 110 patients admitted to acute wards associated with a CMHC and 67 patients admitted to acute wards without a CMHC. Data were collected at baseline, 6 months, and 12 months after admission and groups were compared using repeated-measures analysis of variance (ANOVA), analysis of covariance (ANCOVA), independent sample t-tests, Mann-Whitney U-tests, chi-square tests, and Fisher's exact test. |
The community in-patient units showed better clinical outcomes, significant reduction in unmet needs and higher patient satisfaction compared to the traditional acute wards. |
CMHCs offer significant benefits for patients with severe mental illness and can improve outcomes compared to traditional acute care. |
|
|
Kuno, 2005 |
United States |
Computer Simulation |
Model based on observed medicaid claims from acute and subacute hospitalizations (average daily census, N=52), and monthly residential facility data (average daily census, N=1097) from the County Office of Mental Health in Philadelphia, PA. |
A service system planning model for individuals with serious mental illness |
To understand and improve the planning and management of community psychiatric care systems. |
The study employs a simulation-based approach using a discrete event simulation model to analyze flow between acute hospital beds, subacute hospital beds and residential settings. Key parameters include client arrival rates, service times, and bed capacities. |
The simulation results suggest that an increase in the residential bed capacity or a reduction in the LOS of clients in the residential setting would be an efficient way to reduce congestion. |
The simulation model helps predict how changes in services, such as number of hospital beds or availability of residential programs, impact system performance. |
|
|
Singh et al., 2019 |
United States |
Observational |
Individuals (N=7,800,000) who utilized community mental health services and those who had psychiatric-related emergency department visits (PREDVs) |
Psychiatric-related Revisits to the Emergency Department Following Rapid Expansion of Community Mental Health Services |
Evaluate whether rapid expansion of community health centers (CHCs) correspond with fewer repeat psychiatric-related ED visits (PREDVs) |
Data was collected on psychiatric-related emergency department visits, community health center visits, and demographic characteristics from multiple states over a five-year period. The relationship between the expansion of mental health services at CHCs and the rates of repeat PREDVs was analyzed using regression models. |
The risk of a repeat PREDV decreased with a county-level increase in mental health patients seen at CHCs. The rate ratio indicated 34,000 fewer repeat PREDVs was associated with a 1% expansion in CHC mental health visits. The decline in revisits was for relatively mild/moderate illnesses (e.g., mood, anxiety disorders) compared to more severe illnesses (e.g., schizophrenia/psychoses). |
Greater access to community mental healthcare can effectively alleviate the burden on emergency services for mental health issues. |
|
|
Corcoles et al., 2015 |
Spain |
Quasi-Experimental |
Individuals with Serious Mental Illness (SMI) receiving treatment from either a psychiatric emergency department ( N=448) or home treatment team (HT) ( N= 448). |
Home treatment in preventing hospital admission for moderate and severe mentally ill people |
Determine if HT patients with moderate and severe mental |
Participants receiving either HT or PED were matched 1-1 by diagnosis, gender, and age (± 3 years). The impact of various factors on hospital admission were compared using logistic regression analysis |
Despite HT patients having greater illness severity based on Severity of Psychiatric Illness Scale (SPI) and Global Assessment of Functioning (GAF) (p<0.0001), their likelihood of hospital admission was significantly lower (p<0.0001) due to the advantages of repeated home visits and personalized community-based care |
HT teams are highly effective in reducing hospital admissions for individuals with moderate to severe mental illness when compared to the PED. HT teams could be a valuable alternative to emergency care for managing serious mental health crises, especially for patients who avoid traditional outpatient services. |
|
|
Yu et al., 2015 |
Canada |
Retrospective Cohort |
Older adults (N=226) (age ≥65 years) with severe mental illness admitted to a tertiary care inpatient psychiatric unit |
Predictors of psychiatric re-hospitalization in older adults with severe mental illness |
To identify predictors of psychiatric re-hospitalization in older adults |
Multivariate Cox regression analyses were used to identify potential predictors of psychiatric re-hospitalization, along with bivariate chi-squared and t-tests to examine associations between psychiatric re-hospitalization and potential predictors. |
The results revealed 32.3% of patients required re-hospitalization within the 5-year follow-up period. Significant predictors of shorter time to re-hospitalization included a prior history of psychiatric admissions, living in a supervised setting, and a diagnosis of bipolar disorder (HRs>2.0, p<0.05). |
There is a need for targeted interventions, and clinicians should be vigilant with patients at increased risk. Further research is needed to develop strategies to prevent re-hospitalization in these groups. |
|
|
Green et al., 2014 |
England |
Retrospective Cohort |
Individuals with depression, bipolar disorder, schizophrenia, |
Hospital admission and community treatment of mental disorders in England from 1998 to 2012 |
Evaluate trends in hospital and community treatment in England for eight mental health diagnoses |
Data from the UK Government Health and Social Care Information Centre (HSCIC) was obtained and hospital admissions, lengths of stay, and records of community team activity were statistically analyzed using linear regression, structural equation modeling, and Pearson correlation |
The number of mental health beds fell 39%, from 37,000 to 22,300 over 14 years. There was a significant decline in length of stay and hospital admission for 50% or more of the conditions. Depression had 1000 fewer admissions per year and almost 1 less day in hospital per admission per year. Community treatment activity had little effect on admissions, and years with more available beds had more admissions. |
Despite the shift towards community-based mental health services, community services might not be sufficiently offsetting the need for hospital care. Improvements in the |
|
|
Tint & Lunsky, 2015 |
Canada |
Retrospective Cohort |
Individuals with intellectual disabilities (ID) (N = 66) receiving social or clinical services who visited an urban emergency department (ED) during a crisis |
Individual, social and contextual factors associated with psychiatric care outcomes among patients with intellectual disabilities in the emergency department |
Explore individual, social and contextual factors related to psychiatric care outcomes among patients with ID in the emergency department |
Medical records were reviewed to evaluate psychiatric care outcomes, including psychiatric consultations and hospital admissions, and independent sample t-tests and chi-square tests were used for statistical analysis. |
Individuals with moderate or severe levels of ID (vs. borderline/mild) received a greater proportion of psychiatric consultations and were more likely to be admitted to psychiatric inpatient. Crisis severity scores were significantly greater |
Psychiatric care experiences are variable for patients with ID receiving care in the ED. Improving community mental health services could address healthcare barriers and minimize reliance on emergency services for individuals with ID. Future research is needed to improve care and establish guidelines for providers working with this vulnerable population. |
|
|
Nordstrom et al, 2019 |
United States |
Review |
Review (N =29 articles) drawing on previous research, surveys, and expert opinions on emergency psychiatric care |
Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document |
Provide resource documents with overview and recommendations on psychiatric patient boarding in emergency departments (EDs) |
Descriptive analysis and review of the literature including existing statistics and qualitative expert insights on systemic, social, and hospital-based factors influencing psychiatric patient boarding in EDs |
A shortage of psychiatric inpatient beds, inadequate community mental health resources, and systemic inefficiencies contribute to psychiatric patient boarding in EDs. Negative impacts include prolonged stays, exacerbated psychiatric symptoms, and increased costs. |
Increasing access to mental healthcare by combining psychiatric care with emergency services, using telepsychiatry, adding crisis stabilization units, and optimizing care coordination could reduce the strain on EDs and improve patient care |
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|
a) Subset of articles focused on healthcare system -based factors influencing community mental healthcare utilization |
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Results
Healthcare system-based interventions
Most articles fell into healthcare system level (N=17) with matters related to rates of rehospitalization, emergency department utilization, continuity of care, discharge planning, and integration of psychiatric care into primary or long-term care (Table 1).
A retrospective cohort study from the United Kingdom points to a trend of fewer available hospital beds in the context of a shift to more community-based mental health resources [8]. There was approximately 1,000 fewer admissions per year over a 14-year period and additionally length of stay was found to decline by almost 1 day per admission year [8]. The authors concluded that the relative increasing Community Services might not be enough to compensate for fewer available hospital beds. Other studies have reported similar findings in other geographic regions [9,10]. A computer simulation model using medicaid claims in the United States analyzed the flow between acute hospital beds, subacute hospital beds, and residential settings. The simulation concluded that patient congestion at acute and subacute levels could be alleviated by increasing residential bed capacity or reducing residential length of stay [11].
A large observational study in the United States (N=7,800,000) evaluated how expansion of community mental health services related to emergency room visits. The study concluded that a 1% expansion in community mental health centers was linked to a decrease of 34,000 repeat emergency room visits over a 5-year period [12]. An earlier clinical trial in the United Kingdom compared acute wards associated with a Community Mental Health Center (CMHC) compared to those without and found that patients connected with CMHC had relatively lower healthcare service utilization, greater treatment compliance, and better reported patient experience [13]. A large review article incorporating 29 studies evaluated factors influencing psychiatric patient presentations to emergency departments. The authors conclude that a lack of community mental health resources, shortage of inpatient psychiatric beds, and systemic inefficiencies were contributing factors. The authors conclude that adding crisis stabilization units, incorporating psychiatric care with emergency services, employing telepsychiatry, and improving care coordination could reduce boarding of psychiatric patients in emergency departments [14].
Targeted interventions based on patient's specific factors have also been an important theme. A retrospective cohort study including 266 older adults with severe mental illness identified predictors of increase risks for rehospitalization which included history of psychiatric admissions, shorter time to rehospitalization, bipolar disorder diagnosis, and living in a supervised setting. The authors suggest that clinicians should identify patients at greater risk and incorporate strategies aimed at risk-reduction [15]. A retrospective cohort study evaluated emergency room visits during episodes of crisis for individuals with intellectual disabilities. The authors conclude that specialized crisis management resources within the community could reduce emergency department utilization especially for vulnerable populations [16].
Discharge planning has also been an area of focus for optimizing patient care and reducing healthcare utilization. A retrospective cohort study from the United Kingdom compared individuals with severe mental illness discharged to primary care versus specialized psychiatric care. Despite the group discharge to primary care being more stable on clinical measures there was not a significant difference in acute service use over the 2-year follow-up. Almost 60% of those discharged to primary care were re-referred for specialty mental health services with most cases being related to experiencing a crisis; prior hospitalization was associated with greater likelihood of re-referral and subsequent acute care use [17].
An initial randomized controlled trial from Scotland investigating a transitional discharge model (TDM) which provided support from inpatient nurses as well as peer support following discharge over 5 months. The study concluded that individuals discharged without TRD support were more than twice as likely to be readmitted to the hospital. Outcomes related to symptoms severity and functional ability did not reveal group differences and a major limitation of the study was the small sample size with a total of only 19 participants [18]. A subsequent randomized controlled trial from Canada studied a transitional discharge model (TDM) incorporating continued care from inpatient staff and peer support until community care was established. TDM was not found to be associated with lower post discharge costs or improved quality of life; however, interventions how objects were discharged to community care an average of 116 days earlier per person [19]. A randomized controlled trial from Germany studied the effects of needs-orientated discharge planning on individuals with severe mental illness and a history of high service utilization. Specifically, the study looked at rates of readmission, length of stay, outpatient service use, and quality of life and found no effects on study outcomes in those with needs orientated discharge planning compared to control group [20].
A review article including 16 studies across 7 countries found that outpatient supports including ongoing care with established providers, shared decision making, assistance with medication management, and added support for caregivers improved medication adherence, reduced the number of hospitalizations, and overall improved social functioning and quality of life [21]. A prospective cohort study investigating the effects of continuity of care on readmission rates for individuals with severe mental illness found that the frequency of patient contact with outpatient psychiatric nurses, psychiatrists, or social workers was associated with greater odds of rehospitalization and greater length of stay. The authors conclude that the frequency of outpatient contact may be more reflective of illness severity as opposed to quality of care or lower service utilization [22]. A quasi-experimental study comparing treatment from a psychiatric emergency department as compared to a home treatment team yielded remarkable findings. While home-treatment patients were found to have greater illness severity they had a significantly lower risk of hospital admission which was attributed to the home visits and personalized community care [23].
Several studies have also investigated how the integration of psychiatric care into primary care or long-term care can impact healthcare utilization. A cross-sectional study from China compared mental health service utilization among inpatients in various health care institutions. Specialty psychiatric hospitalization was associated with more severe illness, greater cost, reduced length of stay, being female, younger age and having more comprehensive insurance coverage. The authors conclude that greater integration with primary care, improved health insurance systems, public education, and a more forceful referral system could improve community mental health utilization [24]. A retrospective cohort study in the United States found that for individuals with severe mental illness incorporating non-psychiatric care, psychiatric care, and chemical dependency treatment using a Whole Health Model significantly reduced measures of after utilization. Individuals receiving integrated care were found to have significantly fewer hospitalizations, emergency room visits, office visits, and overall lower expenditures over a 6-year period [25]. An observational study in the United States which included 1225 nursing home eligible participants revealed that on-site Mental and Behavioral Health Services was associated with significantly lower psychiatric inpatient utilization from 129.4 days per 1000 patients to 27.1 days per 1000 patients over a 12-month period which was sustained over 4 years. There was reported increased access to mental health care services for individuals enrolled and greater satisfaction reduced anxiety among interdisciplinary care team members [26].
Community-based interventions
The second most common category were articles (N=10) addressing community-based interventional strategies including assertive community treatment models, clinical case management, crisis response, and community engagement (Table 2).
|
Author Year |
Country |
Design |
Population |
Title |
Objective |
Methods |
Results |
Conclusions |
|
|
Wells, 2013 |
United States |
Randomized Controlled Trial |
Adults (mean age 45.8 ± 12.9 years) with depressive disorder (N=1,018) across 90 Community Engagement and Planning (CEP) and Resources for Services (RS) programs in under-resourced communities of Los Angeles County |
Community-partnered cluster-randomized comparative effectiveness trial of community engagement and planning or resources for services to address depression disparities |
Compare the effectiveness of CEP and RS programs on |
Programs from healthcare, social, and community service sectors were randomly assigned to CEP or RS and quality improvement (QI) outcomes were compared at 6-month follow-up. CEP offered more training with biweekly meetings, increased staff participation, and more total training hours compared to RS |
CEP was more effective than RS in improving mental HRQL, increasing physical activity, and reducing homelessness risk factors. CEP reduced behavioral health hospitalizations and psychiatric medication visits while increasing primary care and faith-based program visits for depression. There was no significant effect on employment or antidepressant use. |
CEP may offer an approach to address multiple |
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|
Guo et al., 2001 |
United States |
Quasi-Experimental |
Community-Based Mobile Crisis Services (CBMCS) cohort (N=1,696) and a hospital-based psychiatric emergency room cohort (N=4,106) of individuals with mental illness |
Assessing the impact of community-based mobile crisis services on preventing hospitalization |
Evaluate the impact of a community-based mobile crisis intervention program on hospitalization rates and timing |
CBMCS included case management and diagnostic assessment, and the team was comprised of crisis specialists, registered nurses and psychiatrists. Cohorts were matched by demographic characteristics, diagnoses, and prior service use. Differences in hospitalization rate and timing were assessed using Cox proportional hazards. |
CBMCS reduced the hospitalization rate by 8%. The hospital-based intervention cohort was 51% more likely to be hospitalized within 30 days following the crisis. Treating more clients in the community did not increase the risk of subsequent hospitalization. |
The study provides evidence that community-based mobile crisis services can effectively reduce hospitalization rates |
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|
Johnson et al., 2005 |
England |
Quasi-Experimental |
Individuals with severe mental illness (N=140) presenting to an emergency department during an acute crisis |
Outcomes of crises before and after introduction of a crisis resolution team |
To compare outcomes of crises before and after implementing a crisis response team (CRT) |
The participants presented either within 6 months prior to implementing the CRT, or within the 9 months following CRT introduction. Logistic regression was used to assess the relationship between the introduction of the CRT and patient admissions within 6 weeks following a crisis |
CRT were associated with a reduction in psychiatric admissions from 71% to 49% and improved patient satisfaction; however, other outcomes such as involuntary hospitalizations, symptoms, social functioning, and quality of life showed no significant differences. |
CRTs may reduce psychiatric admissions and enhance patient satisfaction in the short term, although their effect on broader outcomes may be limited. |
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|
Johnson et al., 2005 |
England |
Randomized Controlled Trial |
Individuals with severe mental illness (N=260) presenting to an emergency department during an acute crisis |
Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study |
To evaluate the relationship between involvement of a crisis resolution team, patient satisfaction, and hospital admission rates |
The experimental group (N=135) received care from a 24-hour crisis resolution team, and a control group (N=125) received standard care from inpatient services and community mental health teams. Outcomes were evaluated using odds ratios, mean differences, and Mann-Whitney tests for skewed data (e.g., bed use). |
The experimental group was less likely to be hospitalized within eight weeks after the crisis (OR= 0.19, 95% CI, 0.11–0.32), although compulsory admissions were not significantly reduced. Mean score differences on the client satisfaction questionnaire (CSQ-8) reached statistical significance after adjusting for baseline characteristics (P=0.002) |
The study contributes to understanding the relationship between community mental healthcare continuity and hospitalization rates, relevant to mental health conditions. |
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|
Jones, 2002 |
United Kingdom |
Clinical Trial |
Individuals with serious mental illness (N=55) at high-risk of hospitalization due to factors such as illness instability and disability |
Assertive community treatment: development of the team, selection of clients, and impact on length of hospital stay |
Study the effect of ACT on hospital utilization and related community resource use |
The analysis compared the duration of hospital stays, frequency of admissions, and total bed days before and after ACT. |
The frequency of admissions and total number of bed days were reduced during the 12 months following ACT intervention. The duration of hospital stays remained unchanged. |
ACT may reduce hospital admissions and community resource use |
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|
Jong, 2019 |
The Netherlands |
Quasi-Experimental |
Adults (>18 years) (N=113) with a psychotic spectrum disorder (schizophrenia, schizoaffective disorder, psychotic disorder NOS, delusional disorder) admitted to a psychiatric hospital at least once in prior 2 years |
An intensive multimodal group programme for patients with psychotic disorders at risk of rehospitalization: a controlled intervention study |
Evaluate whether an intensive multimodal group |
The intervention group (N=52) received the FACT Plus program combined with regular Flexible Assertive Community Treatment (FACT). FACT Plus included psychoeducation, recovery and crisis planning, shared decision making, drug adherence monitoring, and family, sport, and lifestyle interventions. The control group (N=61) received only FACT within a 12-month period. Outcomes were Length of stay (LOS), healthcare costs and compulsory admissions |
FACT Plus significantly reduced psychiatric hospitalizations and there was a 56.1% shorter average LOS. FACT Plus was also associated with reduced healthcare costs and eliminated compulsory admissions entirely in the intervention group |
An intensified treatment program like FACT Plus has the potential to enhance FACT and possibly other community mental health interventions for vulnerable patients at risk of psychiatric rehospitalization |
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|
Hamilton et al., 2015 |
England |
Quasi-Experimental |
Monthly admission rates for patients with a primary diagnosis of any psychosis or schizophrenia admitted to National Health Service Hospitals in England between April 1999 and December 2010 |
The impact of assertive outreach teams on hospital admissions for psychosis: a time series analysis |
Evaluate the impact of Assertive Outreach Teams (AOTs) on hospital |
An interrupted time series analysis with 141 measurement points was used to investigate the impact of the AOT after implementation using data from the Hospital Episodes Statistics (HES) database. |
The expansion of AOTs was associated with significantly reduced hospital admissions for individuals with psychosis, particularly schizophrenia (p<0.0001). There also was a seasonal pattern to admissions, with recurring peaks of admissions in summer months (p<0.0001). |
The AOT model is associated with reducing hospital admissions for people with severe |
|
|
Salkever et al., 1998 |
United States |
Randomized Controlled Trial |
Non-emergency psychiatric patients (N = 144, age 18 to 65 years) with severe, chronic mental illnesses at high risk for hospitalization |
Assertive community treatment for people with severe mental illness: the effect on hospital use and costs |
To determine the effects of Program for Assertive Community Treatment (PACT) on hospital use |
Participants were randomly assigned to one of two PACT groups or a control group receiving usual care. The effect of PACT on hospital use over an 18-month period was assessed using multiple regression analysis. Data were obtained through Medicaid claims, interviews, and hospital databases. |
Those assigned to PACT were approximately 40% less likely to be hospitalized with the effect being stronger among older patients and programs with lower PACT client/staff ratios. PACT did not affect the number of days hospitalized. |
PACT can significantly reduce hospitalizations especially among older patients and in programs with higher client to staff ratios. |
|
|
Holloway & Carson, 1999 |
England |
Randomized Controlled Trial |
Individuals with severe mental illness (N = 70) considered "hard to treat" with schizophrenia, schizoaffective disorder or bipolar disorder |
Intensive case management for the severely mentally ill. Controlled trial. |
Compare intensive clinical case management (ICM) with standard community care in the management of 'hard to treat' patients with a severe mental illness |
Cohort was randomized to ICM group (N = 35) and standard care group (N=35). ICM had caseload of eight clients per core team comprised of four nurses and an occupational therapist, with part-time involvement from psychiatrists and a clinical psychologist. Standard community care provided by community psychiatric nursing services had higher caseloads (approximately 30 patients per worker). Admissions, utilization, symptomatology, functioning, and quality of life were evaluated at 9 months and 18 months using analysis of covariance (ANCOVA), T-tests, and Fisher's exact tests. |
Quality of life was significantly improved in patients receiving ICM at 9 months. Satisfaction with care was significantly greater among case managed patients. All ICM patients remained in contact with services throughout the study, while six control patients were refusing all contact with services at 18 months. There were no differences in patients' symptoms, social behavior or social functioning. |
ICM is associated with greater patient satisfaction, quality of life, maintaining contact for individuals with severe mental illness, but not reduced hospital admissions or emergency visits compared to standard care. |
|
|
Simmonds, 2001 |
Australia, Canada, and England |
Review |
Individuals with severe mental illness (aged 18–65 years) living in urban or inner-city settings. Five studies (N=5) satisfied inclusion criteria based on relevance and study design as randomized or quasi -randomized controlled trials |
Community mental health team management in severe mental illness: a systematic review |
Evaluate benefits of community mental health team management in severe mental illness |
Community mental health team (CMHT) management was compared to standard care. Data were entered into RevMan software for meta-analysis, calculating odds ratios (ORs) and 95% confidence intervals (CIs). |
CMHT groups had shorter duration of in-patient psychiatric treatment and lower costs. There were greater patient satisfaction, fewer dropouts and fewer deaths, especially suicides and suspicious deaths in CMHT groups compared to standard care. |
Compared to standard care CMHT is associated with better patient outcomes, lower rates of suicide, and lower healthcare resource utilization. |
|
|
a) Subset of articles focused on community-based factors influencing community mental healthcare utilization |
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Assertive Community Treatment (ACT) was developed in the 1970s during deinstitutionalization when psychiatric care for those with a serious and persistent mental illness was shifted from state runs psychiatric hospitals to community care [27,28]. The ACT model aims to encourage participant independence and community integration with the assistance of a multidisciplinary team often providing home-based treatment options [29]. A randomized control trial in the United States in the late 90s reported a 40% reduced likelihood of hospitalization for individual with severe and persistent mental illness over an 18-month period [30]. The reduction was particularly noticeable among older patients and in programs with lower client / staff ratios; however, there was no effect on length of hospital stay [30]. A subsequent clinical trial in the United Kingdom reported that ACT was associated with an overall reduction in hospital admissions and total number of bed days over a 12-month period; similarly, ACT was not associated with a reduction in length of hospital stay [31]. Other programs have been developed like Flexible Assertive Community treatment (FACT) which is a more flexible, individualized version of ACT. A quasi-experimental study from the Netherlands evaluated whether a FACT Plus program incorporating shared decision making, psychoeducation, crisis planning, drug adherence monitoring, and family, physical activity, and lifestyle interventions would be superior to FACT alone. The authors report that FACT Plus was associated with reduced rate of psychiatric hospitalization, a 56.1% shorter average length of stay, and reduced healthcare costs [32]. A more recent quasi experimental study investigating Hospital Episode Statistics from the National Health Service (NHS) in England found a highly significant association between the expansion of assertive outreach teams and reduction hospital admissions over an 11-year period (p<0.0001) [33].
Specialized community crisis response teams have also been shown to have a positive impact on community psychiatric healthcare utilization. A large quasi-experimental study in the United States compared individuals receiving care in a hospital-based psychiatric emergency room (N=4106) to individuals receiving community-based mobile crisis services (N=1696) (CBMCS) [34]. Those receiving care in the hospital-based emergency room were 51% more likely to be hospitalized within 30 days following the crisis and CBMCS reduced hospitalization rate by 8% [34]. A subsequent quasi-experimental study in England compared outcomes of those with severe mental illness experiencing a crisis treated in an emergency department both before and after implementation of a crisis response team (CRT) [35]. Individuals receiving CRT were 60% less likely to be admitted and CRT was associated with improved patient's satisfaction [35]. A subsequent randomized controlled trial by the same author reported that individuals with severe mental illness reported in the emergency department who received crisis resolution services were 80% less likely to be hospitalized within 8 weeks following the crisis compared to individuals receiving emergency care as usual [36]; furthermore patient's satisfaction was also significantly greater for those patients receiving CRT services after adjusting for baseline characteristics [36].
Other strategies within the community associated with reducing healthcare service utilization include case management. A randomized controlled trial from England compared a group of individuals with severe mental illness and a history of being “hard to treat” receiving intensive case management to a controlled group receiving standard care. The intensive case management (ICM) group had multidisciplinary support from community mental health care providers including nursing, therapists, and psychiatrists as compared to community psychiatric nursing services which had higher caseloads per worker. ICM was associated with improved communication, greater patient satisfaction, and quality of life but there was no significant difference in rates of hospital admission or emergency room visits [37]. A subsequent review article incorporating 5 studies from Australia, Canada, and England concluded that individuals with severe mental illness receiving Community Mental Health Team (CMHT) management had reduced length of stay during psychiatric hospitalization and reduced healthcare resource utilization. There were also better patient outcomes including greater patient satisfaction, lower attrition rates, and fewer deaths including suicides [38]. A randomized controlled trial in a large metropolitan area of the United States evaluated the effectiveness of community programs receiving community engagement and planning (CEP), which included more frequent meetings, more training offerings, and greater staff participation, compared to community programs receiving resources for services (RS). The adults (N=1018) assigned to programs receiving CEP had a lower rate of psychiatric hospitalizations and visits for psychiatric medication management compared to those enrolled in programs assigned to RS [39]. The authors conclude that CEP could address community mental health care disparities through integrated healthcare-community partnerships [39].
Individual-based interventions
Finally, there were several articles (N=9) relevant to the individual level including family contact, patient autonomy, shared decision making, compulsory treatment and communication with providers (Table 3).
|
Author Year |
Country |
Design |
Population |
Title |
Objective |
Methods |
Results |
Conclusions |
|
|
Haselden et al., 2019 |
United States |
Clinical Trial |
Psychiatric inpatients (N=179) from two urban hospitals with serious mental illnesses, all of whom were Medicaid recipients |
Family Involvement in Psychiatric Hospitalizations: Associations With Discharge Planning and Aftercare Attendance |
Investigate the relationship between family support and discharge outcomes for individuals hospitalized with severe mental illness |
Participants hospitalized between 2012 and 2013 were randomly selected and logistic regression models were used to assess the relationship between family involvement and three outcomes: comprehensive discharge planning, attendance at outpatient mental health appointments within seven days, and attendance within 30 days. |
Family involvement was positively associated with comprehensive discharge planning (including communication with outpatient providers, scheduling follow-up appointments, and forwarding a discharge summary). Family involvement was associated with significantly higher rates of attending outpatient appointments within seven days (53%) and 30 days (78%) post-discharge. |
Family contact and communication during inpatient hospitalization plays a crucial role in comprehensive discharge planning and receiving prompt post-hospitalization care |
|
|
Olfson et al., 1998 |
United States |
Observational |
Medicaid-eligible adult psychiatric inpatients (N=104) diagnosed with schizophrenia or schizoaffective disorder |
Linking inpatients with schizophrenia to outpatient care |
Determine whether communication between the patients and their |
Outpatient referral compliance, psychiatric symptoms, medication compliance, homelessness risk, and hospital readmission or emergency visits were compared between patients who had contact (phone or face-to-face) with an outpatient clinician before discharge (N = 53) and those who did not (N=51). Data was evaluated at hospital discharge and three months post-discharge using descriptive statistics, chi-square tests, Student’s t-tests, and multiple linear regression. |
There were no significant differences in hospital readmissions or emergency room visits. However, patients with predischarge communication were more likely to complete outpatient referrals, had better control over psychiatric symptoms. and reported less difficulty managing symptoms. |
Communication between inpatients and new outpatient clinicians does not appear to be associated with reduced rates of readmission or emergency room visits; however, it may ease the transition to outpatient care and contribute to better control of symptoms. |
|
|
Cosh et al., 2017 |
Germany, United Kingdom, Italy, Hungary, Denmark, and Switzerland |
Observational |
Individuals (N =588) aged 18–60 with history of severe mental illness |
Clinical Decision Making and Mental Health Service Use Among Persons With Severe Mental Illness Across Europe |
Explore relationship between clinical decision making (CDM) and service use among persons with severe mental illness |
Associations between CDM preferences among staff and patients (active, passive, or shared) and mental health service use were evaluated using binomial regressions over 12 months |
Preference for active involvement in decision-making was associated with longer hospital stays and higher costs. Shared decision-making was linked to reduced costs and fewer admissions. Low patient-rated satisfaction with decision-making was associated with higher costs. |
Shared decision-making may help reduce healthcare costs by decreasing inpatient admissions. Greater patient satisfaction with decision-making processes could also contribute to lower costs. |
|
|
Sigrunarson, 2017 |
Norway |
Randomized Controlled Trial |
Individuals (N=54) with severe persistent mental illness (SPMI) and history extensive mental health service use admitted to a Community Mental Health Centre (CMHC) |
A randomized controlled trial comparing self-referral to inpatient treatment and treatment as usual in patients with severe mental disorders |
To investigate whether SRIT could yield better outcomes after 12 months in use of mental health services for people with severe mental disorders than Treatment As Usual (TAU). |
Balanced randomization into two groups: 1) Treatment as usual (TAU) received standard psychosocial and pharmacological treatment and 2) Self-referral to inpatient treatment (SRIT) received TAU, but was allowed to admit themselves for up to 5 days per admission |
No significant differences in total inpatient days, admissions, or outpatient contacts. However, the SRIT group had more admissions. Both groups saw a 40% reduction in inpatient days over the study period. |
SRIT model did not reduce service use but may enhance patient autonomy, offering a more patient-centered approach without increasing healthcare resource use. |
|
|
Kisely, 2014 |
United States and England |
Meta-Analysis |
Individuals with severe mental illness (N= 749) across three randomized controlled trials (RCTs) |
An updated meta-analysis of randomized controlled evidence for the effectiveness of community treatment orders |
Evaluate if community treatment orders (CTOs) reduce health service use or improve clinical and social outcomes for individuals with severe mental illness |
The study compared CTOs with voluntary or standard care. Primary outcomes were psychiatric readmissions and bed days over a 12-month follow-up period. Secondary outcomes included psychiatric symptoms and social functioning measured with Global Assessment of Functioning (GAF). |
CTOs did not significantly reduce readmissions (risk ratio 0.98; 95% CI 0.82 to 1.16) or bed days (mean difference –16.36; 95% CI –40.8 to 8.05). There were no significant differences in psychiatric symptoms (standardized MD –0.03; 95% CI –0.25 to 0.19) or Global Assessment of Functioning (MD –1.36; 95% CI –4.07 to 1.35). |
CTOs are not associated with significant differences in readmission, psychiatric symptoms or social functioning compared to standard care. |
|
|
Barnett, 2018 |
United Kingdom, USA, Australia, Netherlands, Sweden, Spain, and Canada |
Meta-Analysis |
Individuals with severe mental illness (N = 57746) across 39 randomized controlled trials (RCTs), contemporaneous controlled comparison studies, and observational pre-post studies |
Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis |
Determine the effectiveness of Compulsory Community Treatment (CCT) for individuals with severe mental illness |
Researchers analyzed included studies using a random-effects model to determine impact of CCT on readmission rates, inpatient bed-days, use of community services, and treatment adherence |
CCT may improve community service engagement and outpatient treatment adherence. However, there is no consistent evidence indicating CCT significantly reduces hospital readmissions or inpatient stay duration. |
CCT is difficult to justify due to lack of consistent evidence, coercive nature, and potential for increased cost. CCT may be beneficial for only select clinical groups (e.g., more severe illness). Alternatively, providing more accessible, high-quality community support than currently available may result in increased benefits |
|
|
Burns, 2013 |
United Kingdom |
Randomized Controlled Trial |
Adults (aged 18-65-years) involuntarily hospitalized for psychosis (N=336). Participants were eligible if they could give informed consent and were suitable for supervised outpatient care. |
Community treatment orders do not reduce hospital readmission in people with psychosis |
Compare effectiveness of community treatment orders (CTOs) which have a fixed-period of supervision for 6 months to Section 17 orders which have short-term discretionary supervision |
CTO (N=167) and Section 17 (N=169) groups were compared over 12 months. Hospital readmissions, length of stay, global assessment of functioning (GAF) and Brief Psychiatric Rating Scale (BPRS) outcomes were compared using relative risks, incident density ratios, and adjusted mean differences. |
There were no significant difference between CTO and Section 17 groups in hospital readmission rates (both 36%), time to first readmission, number of readmissions, or total days of hospitalization. There were no group differences in GAF and BPRS scores. |
Following involuntary hospitalization CTOs with a fixed-period of supervision may not confer benefits over short-term discretionary supervision in reducing hospital readmission or improving clinical outcomes. |
|
|
Vine et al., 2016 |
Australia |
Retrospective Cohort |
Individuals with severe mental illness (N=1,478) who had been on a Community Treatment Order (CTO) for at least three months prior to CTO discharge |
Mental health service utilization after a Community Treatment Order: A comparison between three modes of termination |
Examine service utilization and legal status following CTO termination by a Mental Health Review Board (MHRB), treating psychiatrist or order expiration |
Relationship between discharge mode (by MHRB, treating psychiatrist, or expiration) and subsequent service utilization (readmission rate, return to involuntary status, and ongoing service engagement) were compared using logistic regression controlling for age, sex, location, and days on order. |
Individuals discharged from CTO by treating psychiatrists (88%) were less likely to be subsequently placed under an involuntary order than those discharged by MHRB (5%) or by expired order (7%) (odds ratio = 0.61) |
Abrupt discharge from CTOs may lead to higher relapse rates and future need for compulsory treatment. Discharge planning and community engagement are crucial for reducing relapse rates and improving outcomes |
|
|
Fitzpatrick et al., 2004 |
England |
Observational |
Individuals with severe mental illness (N=349) receiving care from 50 different general practices in inner London |
The determinants and effect of shared care on patient outcomes and psychiatric admissions - an inner city primary care cohort study |
Determine factors associated with receipt of different levels of shared care, and the effect of shared care on patient outcomes |
Standardized questionnaires were completed by patients and general practitioners at baseline and after 12 months which included the Shared Care Assessment Schedule (SCAS), Comprehensive Psychopathological Rating Scale (CPRS), Social Functioning Questionnaire (SFQ), and Global Assessment of Functioning (GAF). Chi-squared, ordered logistic regression, analysis of variance, and analysis of covariance were employed for statistical analysis. |
After adjustment for age, sex and psychiatric diagnosis shared care was not associated with improved clinical, social or general health functioning over one year. Shared care did not have a prospective effect on psychiatric admissions. |
High shared cared may have limited impact on healthcare outcomes and patient satisfaction over time. |
|
|
a) Subset of articles focused on individually-based factors influencing community mental healthcare utilization |
|||||||||
An observational study in United States evaluated the impact of patient communication (phone or face-to-face) with new outpatient providers prior to discharge in individuals with schizophrenia spectrum disorders. The authors report no significant difference in the number of emergency room visits or hospital readmissions; however, those with pre-discharge communication had better control of psychiatric symptoms and were more likely to complete outpatient referrals [40]. A more recent clinical trial from the United States evaluated the relationship between family involvement and discharge outcomes for individuals with severe mental illness. Family involvement was associated with improved communication with outpatient providers, comprehensive discharge planning, and increased likelihood attending outpatient appointments within 30 days of discharge [41].
As it pertains to clinical decision making, an observational study investigated decision making preferences and experiences for both patients and community-based outpatient providers in several European countries. Preferences for shared clinical decision-making which included greater patient involvement were shown to be associated with lower costs and fewer psychiatric hospitalizations [42]. Greater patient satisfaction with clinical decision making at outpatient appointments was associated with reduced healthcare service utilization [42]. A related randomized controlled trial evaluated a self-referral for inpatient treatment (SRIT) program whereby patients with severe and persistent mental illness were offered the ability to self-refer and admit themselves for inpatient treatment for up to 5 days at a time over the course of 12 months [43]. There were no significant differences in the number of admissions, total inpatient days, or outpatient contacts in the SRIT group compared to those receiving treatment as usual; the authors conclude that the SRIT model offered more of a patient's centered approach and enhanced autonomy without increasing healthcare resource use [43].
A randomized controlled trial in the United Kingdom investigated the effectiveness of community treatment orders for individuals involuntarily hospitalized for psychosis compared to short-term discretionary supervision [44]. Community treatment orders (CTOs) or compulsory community treatment (CCT) are legal orders for compulsory mental health treatment similar to outpatient commitment, which have a fixed period of supervision for 6 months [45]. There were no significant group differences in readmission rates, total number of days hospitalized, time to first readmission, control of symptoms or level of functioning over the course of 12 months [44]. A meta-analysis including 3 randomized controlled trials (N=749) similarly reported no significant differences in hospital readmission rates, number hospitalization days, or clinical outcomes between CTOs and voluntarily or standard care in individuals with severe mental illness [46]. A subsequent larger meta-analysis which included 4 randomized controlled trials in addition to 35 other studies (N=57746) also found no significant differences in rates of hospital readmission or inpatient stay durations between those receiving compulsory treatment [47]. The authors conclude that compulsory treatment lacks evidence and has potential for increased cost; it may be beneficial for only a select group of patients with more severe illnesses [47]. Regarding discharge from CTOs, a retrospective cohort study reported higher rates of relapse and service utilization in those abruptly discharged from CTOs either by expiration or by mental health review board as compared to those discharged by established outpatient psychiatrist [48].
An observational study from England investigated a relationship between healthcare utilization and clinical outcomes with perceptions of shared care as reported by general practitioners caring for individuals with severe mental illness [49]. After adjusting for age, psychiatric diagnosis, and sex, higher levels of shared care were not associated with changes in clinical outcomes or healthcare service utilization including rates of admission or length of stay over a 12 month; the authors include that high shared care may have limited impact on healthcare outcomes over time [49].
Discussion
This review article sets out to identify potential strategies aimed at optimizing community psychiatric patient care while also providing good stewardship of community resources. Striking this balance is challenging with many subtle factors impacting healthcare utilization. Upon review of the 36 articles, factors at the level of the healthcare system, community level, and individual level were identified as influencing utilization of community emergency department and inpatient psychiatric hospitalization resources.
In the absence of initial access to specialized psychiatric care, patients are often not triaged into an evidence-based pathway best suited for management of their illness. Preemptively triaging patients into distinctive levels of care could not only minimize risk of illness progression but also minimize utilization of resources designed for managing more severe symptoms. Integrating psychiatric care into primary care opens the door to specialized psychiatric resources while at the same time removing potential barriers to care. Patients at greatest risk of repeated emergency department evaluation or psychiatric hospitalization could be directed toward treatment alternatives. Mental health resources could be directly integrated into schools, homes, businesses or via technology [50]. For example, home-based treatments and/or self-referral for inpatient treatment programs (SRIT) have potential to reduce the number of hospitalizations while maintaining a patient-centered approach for individuals with severe psychiatric disease [23,43].
Additionally, inferential factors depending on geographic region can provide important clues related to the likelihood of using community mental health resources. A study from Seoul, Korea, demonstrated that a longer duration of illness, increased stress levels, greater internalized stigma, and being male were associated with greater likelihood of using community mental health resources [51]. In rural Ethiopia those with a higher income, increased symptomatic severity, having a perceived need for care, and psychoactive substance use were factors associated greater likelihood of utilizing community mental health services [52]. Interestingly, however only about 1/3 of individuals suffering from mood or anxiety disorders utilized Community Mental services [52].
A repeating theme impacting healthcare utilization points to the effectiveness of structured community programs. There is substantial evidence associating programs like Assertive Community Treatment (ACT) and Flexible Assertive Community Treatment (FACT) with lower rates of hospitalization and reduced length of stay [30–33]. Community Based Mobile Crisis Services (CBMCS) and Crisis Response Teams (CRT) similarly have been shown to positively impact rates of hospitalization and improve patient satisfaction [34,35]. Also, transitional discharge models (TDM) have been shown to reduce the number of psychiatric hospitalizations and reduce length of stay while streamlining care transitions [18,19]. Integrating aspects of these programs into hybrid models may prove to be even more beneficial for certain patient populations, which should be explored as part of future research studies.
At the individual level, a sense of involvement in the care plan has been associated with reduced costs, reduced utilization, and greater patient satisfaction. Conversely, from the perspective of the provider their interpretation of level of shared care has not been found to be associated with changes in clinical outcomes, length of stay, or other measures of healthcare utilization [49]. These findings speak to the importance of patient autonomy in influencing treatment success and the utilization of resources. In fact, multiple studies have demonstrated no relationship between compulsive treatment orders and readmission rates, length of stay, and symptomatic control among other clinical outcomes [44,46,47]. Importantly, frequent communication between the patient and healthcare team members, family involvement, and community inclusion have all been associated with improved control of symptoms and greater likelihood of attending appointments [40,41].
Conclusion
Community based, healthcare-system based, and individually based factors all impact the utilization of community mental health resources. As opposed to a dichotomous treatment model (i.e., inpatient vs. outpatient), hybrid, multi-tiered models could potentially reduce systematic inefficiencies, improve stewardship, and optimize patient outcomes. In treating complex psychiatric diseases which have an array of biopsychosocial underpinnings, a “one-size-fits-all” approach is not adequate nor realistic. Evidence-based pathways, individualized for specific patient populations and associated risk factors desperately need to be developed and explored as part of future research studies. Bioinformatics and artificial intelligence hold specific promise especially in the context of Learning Health Systems (LHS). LHS could synthesize clinical data from medical records in repeatable research cycles to continuously evaluate and improve healthcare outcomes [53]. Future research studies are urgently needed to better understand how LHS can be aid in the development of evidence based treatment and streamline the utilization of community mental healthcare resources [53].
Conflicts of Interest
Neither J. Baruth nor M. Hammel have any conflicts of interest to declare.
Acknowledgments
We would like to specifically thank Ellen M. Aaronson, M.S., AHIP of Mayo Clinic Libraries for conducting library search of the MEDLINE database.
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