Service utilization research: goals and prospects

Discharge planning in mental health care: a systematic review of the recent literature

OBJECTIVE

To determine and estimate the efficacy of discharge planning interventions in mental health care from in-patient to out-patient treatment on improving patient outcome, ensuring community tenure, and saving costs.

METHOD

A systematic review and meta-analysis identified studies through an electronic search on the basis of defined inclusion and exclusion criteria and extracted data.

RESULTS

Of eleven studies included, six were randomised controlled trials, three were controlled clinical trials, and two were cohort studies. The discharge planning strategies used varied widely, most were limited to preparation of discharge during in-patient treatment. Pooled risk ratios were 0.66 (95% CI = 0.51 to 0.84; P < 0.001) for hospital readmission rate, and 1.25 (1.07 to 1.47; P < 0.001) for adherence to out-patient treatment. Effect sizes (Hedge's g) were -0.25 (-0.45 to -0.05; P = 0.02) for mental health outcome, and 0.11(-0.05 to 0.28; NS) for quality of life.

CONCLUSION

Discharge planning interventions are effective in reducing rehospitalisation and in improving adherence to aftercare among people with mental disorders.

Needs-oriented discharge planning and monitoring for high utilisers of psychiatric services (NODPAM): design and methods

Background

Attempts to reduce high utilisation of psychiatric inpatient care by targeting the critical time of hospital discharge have been rare.

Methods

This paper presents design and methods of the study "Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services" (NODPAM), a multicentre RCT conducted in five psychiatric hospitals in Germany. Inclusion criteria are receipt of inpatient psychiatric care, adult age, diagnosis of schizophrenia or affective disorder, defined high utilisation of psychiatric care during two years prior to the current admission, and given informed consent. Consecutive recruitment started in April 2006. Since then, during a period of 18 months, comprehensive outcome data of 490 participants is being collected at baseline and during three follow-up measurement points.

The manualised intervention applies principles of needs-led care and focuses on the inpatient-outpatient transition. A trained intervention worker provides two intervention sessions: (a) Discharge planning: Just before discharge with the patient and responsible clinician at the inpatient service; (b) Monitoring: Three months after discharge with the patient and outpatient clinician. A written treatment plan is signed by all participants after each session.

Primary endpoints are whether participants in the intervention group will show fewer hospital days and readmissions to hospital. Secondary endpoints are better compliance with aftercare, better clinical outcome and quality of life, as well as cost-effectiveness and cost-utility.

Discussion

If a needs-oriented discharge planning and monitoring proves to be successful in this RCT, a tool will be at hand to improve patient outcome and reduce costs via harmonising fragmented mental health service provision.

Trial Registration

ISRCTN59603527

Pattern of care for schizophrenia patients in Granada (Spain): a case register study

AIMS

This study sets out to explore the use flow of mental health services by a cohort of patients with schizophrenia located in Granada (Spain).

METHODS

All cases (N = 844) included in the analysis were users of the community mental healthcare public service provided in the area. The Markov chain model was used to calculate the probability of transition from one type of contact with mental health services resources to another type of contact in the next month, over a three-year follow-up.

RESULTS

For a given one-month period, for each level of service contact, most patients continued to use the same level of care.

CONCLUSIONS

Our results can be interpreted as a reflection of adequate continuity of mental health care provided by the Andalusian community service.