Depression and Coleman Care Transitions Intervention

Transitional Care Support for Medicaid-Insured Patients With Serious Mental Illness: Protocol for a Type I Hybrid Effectiveness-Implementation Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND

People diagnosed with a co-occurring serious mental illness (SMI; ie, major depressive disorder, bipolar disorder, or schizophrenia) but hospitalized for a nonpsychiatric condition experience higher rates of readmissions and other adverse outcomes, in part due to poorly coordinated care transitions. Current hospital-to-home transitional care programs lack a focus on the integrated social, medical, and mental health needs of these patients. The Thrive clinical pathway provides transitional care support for patients insured by Medicaid with multiple chronic conditions by focusing on posthospitalization medical concerns and the social determinants of health. This study seeks to evaluate an adapted version of Thrive that also meets the needs of patients with co-occurring SMI discharged from a nonpsychiatric hospitalization.

OBJECTIVE

This study aimed to (1) engage staff and community advisors in participatory implementation processes to adapt the Thrive clinical pathway for all Medicaid-insured patients, including those with SMI; (2) examine utilization outcomes (ie, Thrive referral, readmission, emergency department [ED], primary, and specialty care visits) for Medicaid-insured individuals with and without SMI who receive Thrive compared with usual care; and (3) evaluate the acceptability, appropriateness, feasibility, and cost-benefit of an adapted Thrive clinical pathway that is tailored for Medicaid-insured patients with co-occurring SMI.

METHODS

This study will use a prospective, type I hybrid effectiveness-implementation, stepped-wedge, cluster randomized controlled trial design. We will randomize the initiation of Thrive referrals at the unit level. Data collection will occur over 24 months. Inclusion criteria for Thrive referral include individuals who (1) are Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) reside in Philadelphia; (3) are admitted for a medical diagnosis for over 24 hours at the study hospital; (4) are planned for discharge to home; (5) agree to receive home care services; and (6) are aged ≥18 years. Primary analyses will use a mixed-effects negative binomial regression model to evaluate readmission and ED utilization, comparing those with and without SMI who receive Thrive to those with and without SMI who receive usual care. Using a convergent parallel mixed methods design, analyses will be conducted simultaneously for the survey and interview data of patients, clinicians, and health care system leaders. The cost of Thrive will be calculated from budget monitoring data for the research budget, the cost of staff time, and average Medicaid facility fee payments.

RESULTS

This research project was funded in October 2023. Data collection will occur from April 2024 through December 2025. Results are anticipated to be published in 2025-2027.

CONCLUSIONS

We anticipate that patients with and without co-occurring SMI will benefit from the adapted Thrive clinical pathway. We also anticipate the adapted version of Thrive to be deemed feasible, acceptable, and appropriate by patients, clinicians, and health system leaders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06203509; https://clinicaltrials.gov/ct2/show/NCT06203509.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64575.

Transitional care programs to improve the post-discharge experience of patients with multiple chronic conditions and co-occurring serious mental illness: A scoping review

The transition from hospital to home can be especially challenging for those with multiple chronic conditions and co-occurring serious mental illness (SMI). This population tends to be Medicaid-insured and disproportionately experiences health-related social needs. The aim of this scoping review was to identify the elements and outcomes of hospital-to-home transitional care programs for people diagnosed with SMI. A scoping review was conducted using Arksey and O'Malley's methodology. Three databases were searched; ten articles describing eight transitional care programs published from 2013 to 2024 met eligibility criteria. Five programs focused on patients being discharged from a psychiatric admission. Five of the interventions were delivered in the home. Intervention components included coaching services, medication management, psychiatric providers, and counseling. Program lengths ranged from one month to 90 days post-hospitalization. These programs evaluated quality of life, psychiatric symptoms, medication adherence, readmissions, and emergency department utilization. Notably, few programs appeared to directly address the unmet social needs of participants. While the focus and components of each transitional care program varied, there were overall positive improvements for participants in terms of improved quality of life, increased share decision making, and connections to primary and specialty care providers.

Organizational readiness for change towards implementing a sepsis survivor hospital to home transition-in-care protocol

Background

Organizational readiness for change, defined as the collective preparedness of organization members to enact changes, remains understudied in implementing sepsis survivor transition-in-care protocols. Effective implementation relies on collaboration between hospital and post-acute care informants, including those who are leaders and staff. Therefore, our cross-sectional study compared organizational readiness for change among hospital and post-acute care informants.

Methods

We invited informants from 16 hospitals and five affiliated HHC agencies involved in implementing a sepsis survivor transition-in-care protocol to complete a pre-implementation survey, where organizational readiness for change was measured via the Organizational Readiness to Implement Change (ORIC) scale (range 12-60). We also collected their demographic and job area information. Mann-Whitney U-tests and linear regressions, adjusting for leadership status, were used to compare organizational readiness of change between hospital and post-acute care informants.

Results

Eighty-four informants, 51 from hospitals and 33 from post-acute care, completed the survey. Hospital and post-acute care informants had a median ORIC score of 52 and 57 respectively. Post-acute care informants had a mean 4.39-unit higher ORIC score compared to hospital informants (p = 0.03).

Conclusions

Post-acute care informants had higher organizational readiness of change than hospital informants, potentially attributed to differences in health policies, expertise, organizational structure, and priorities. These findings and potential inferences may inform sepsis survivor transition-in-care protocol implementation. Future research should confirm, expand, and examine underlying factors related to these findings with a larger and more diverse sample. Additional studies may assess the predictive validity of ORIC towards implementation success.

Effects of Transitional Care Model-Based Interventions for Stroke Patients and Caregivers on Caregivers' Competence and Patient Outcomes: Randomized Controlled Trial

This study evaluated the effectiveness of the Transitional Care Model Stroke Turkey for stroke patients and caregivers as regards the competence of caregivers and patient outcomes. It is a parallel-group, assessor-blinded monocenter conducted with 126 participants in total (66 intervention included 33 stroke patients and 33 caregivers; 60 control groups included 30 stroke patients and 30 caregivers), between March and August 2018. The Transitional Care Model Stroke Turkey program lasts for 13 to 20 weeks. It includes a 12-week follow-up after discharge, a minimum of three hospital visits, one home visit, minimum 18 phone calls, and Web-based training. The intervention group exhibited better caregiver competence (13.48 ± 2.31), preparation for care (28.48 ± 4.74), and e-health literacy (34.42 ± 4.74) than the control group (respectively, 11.37 ± 2.48, 20.93 ± 7.10, 26.93 ± 8.53) ( P < .001). Emotional exhaustion and depersonalization increased in the control group, but remained the same in the intervention group. Personal accomplishment decreased in the intervention group, unlike in the control group. Within 12 weeks of discharge, five patients from the intervention group and seven patients from the control group were rehospitalized. There was no statistical difference between stroke patients in either group in terms of having previously used home healthcare services. The Transitional Care Model Stroke Turkey is a practical model for stroke patients transitioning from hospital to home.

Care transitions intervention reduces ED revisits in cognitively impaired patients

Introduction

About half of older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We tested the effect of an adapted Care Transitions Intervention (CTI) at reducing ED revisits in this vulnerable population.

Methods

We conducted a pre-planned subgroup analysis of community-dwelling, cognitively impaired older (age ≥60 years) participants from a randomized controlled trial testing the effectiveness of the CTI adapted for ED-to-home transitions. The parent study recruited ED patients from three university-affiliated hospitals from 2016 to 2019. Subjects eligible for this sub-analysis had to: (1) have a primary care provider within these health systems; (2) be discharged to a community residence; (3) not receive care management or hospice services; and (4) be cognitively impaired in the ED, as determined by a score >10 on the Blessed Orientation Memory Concentration Test. The primary outcome, ED revisits within 30 days of discharge, was abstracted from medical records and evaluated using logistic regression.

Results

Of our sub-sample (N = 81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.07 to 0.90) but not 14 days (OR 1.01, 95% CI 0.26 to 3.93). Multivariate analysis of outpatient follow-up found no significant effects.

Discussion

Community-dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.