Measures of Care Coordination at Inpatient Psychiatric Facilities and the Medicare 30-Day All-Cause Readmission Rate

Quality and Safety Indicators for Care Transitions by Older Adults: A Scoping Review

OBJECTIVE

To identify quality and safety indicators routinely used to monitor, evaluate, and improve care transitions for older adults globally.

DESIGN

A scoping literature review.

SETTING AND PARTICIPANTS

This review identified indicators used internationally to monitor and evaluate the quality and safety of care transitions by older adults. Care transitions were defined as the transfer of health care at least once between care settings.

METHODS

A search of academic and gray literature identified indicators that were publicly available, used routinely at the population level, and reported on since 2012. Indicators were summarized by care domain (ie, hospitalization, consumer experience, access/waiting times, communication, follow-up, and medication-related), type (structure, process, outcome), quality dimension (patient centeredness, timeliness, effectiveness, efficiency, safety, and equity), data collection approach, reporting strategies, and care settings involved.

RESULTS

The review identified 361 quality indicators from 89 programs across 12 countries. Care domains included hospitalization (n = 112; 31.0%), consumer experience (n = 82; 22.7%), access/waiting times (n = 63; 17.5%), communication (n = 40; 11.1%), follow-up (n = 40; 11.1%), and medication-related (n = 24; 6.6%). Indicators measured outcomes (n = 227; 62.9%) or processes (n = 134; 37.1%) and represented the dimensions of patient centeredness (n = 155, 42.9%), timeliness (n = 91; 25.2%), and effectiveness (n = 87; 24.1%), efficiency (n = 18; 5.0%) and safety (n = 10; 2.8%). Most indicators were constructed from survey (n = 160; 44.3%) or administrative data (n = 138; 38.2%); 69% (n = 249) were publicly reported and 80% (n = 287) measured transitions related to acute settings.

CONCLUSIONS AND IMPLICATIONS

Eighty-nine international programs routinely monitor the quality and safety of care transitions, and focus on the domains of hospitalization, access and waiting times, and communication. Considering the vulnerability of older adults as they transition across settings and providers, it is important to ensure holistic measurement of the quality of these care transitions to identify sub-optimal transitions, inform quality improvement, and ultimately improve outcomes for older adults.

Assessing the Incremental Health Care Utilization and Expenditures Associated With Serious Psychological Distress by Living Arrangements Among Older Adults

Older adults suffering from serious psychological distress (SPD) have higher health care utilization and expenditures. However, it is unknown whether living alone might further amplify differences in health care usage and costs among older adults with SPD. Using pooled data from 2007-2019 Medical Expenditure Panel Survey, we estimated the incremental care expenditures and utilization associated with SPD among older adults living alone and living with others. The results show that in both living arrangements, having SPD is associated with increases in emergency department visits, hospital admissions, and prescription fill-ups, which leads to higher total prescription expenditures. However, the incremental differences of SPD-related incremental usage and expenditures between older adults living alone and living with others were similar. Our findings call for targeted community programs for older adults that go beyond eliminating physical loneliness, and innovative care coordination strategies that prioritize mental health and preventative care among older adults.

Association of Inpatient Occupational Therapy Utilization With Reduced Risk for Psychiatric Readmission Among Veterans

OBJECTIVE

The authors sought to investigate whether utilization of inpatient occupational therapy (OT) was associated with reduced risk for 30-day psychiatric readmission in the Veterans Health Administration (VHA).

METHODS

The authors conducted a secondary analysis of VHA medical record data for veterans who received inpatient psychiatric care from 2015 to 2020 (N=176,889). Mixed-effects logistic regression was used to model psychiatric readmission within 30 days of discharge (yes or no) as a function of inpatient psychiatric OT utilization (none, one, two, three, or four or more encounters) and other care utilization (e.g., previous psychiatric hospitalization), as well as clinical (e.g., primary diagnosis), sociodemographic (e.g., race-ethnicity), and facility (e.g., complexity) characteristics. Sensitivity analyses were conducted to evaluate the robustness of findings (e.g., stratification by discharge disposition).

RESULTS

Relatively few veterans received inpatient psychiatric OT (26.2%), and 8.4% were readmitted within 30 days. Compared with veterans who did not receive inpatient psychiatric OT, those with one (OR=0.76), two (OR=0.64), three (OR=0.67), or four or more encounters (OR=0.64) were significantly (p<0.001) less likely to be readmitted within 30 days. These findings were consistent across all sensitivity analyses.

CONCLUSIONS

Veterans who received inpatient OT services were less likely to experience psychiatric readmission. A clear dose-response relationship between inpatient psychiatric OT and readmission risk was not identified. These findings suggest that OT services may facilitate high-value inpatient psychiatric care in the VHA by preventing readmissions that stymie recovery and incur high costs. Future research may establish the causality of this relationship, informing policy regarding increased access to inpatient psychiatric OT.

American Psychiatric Nurses Association Position: Staffing Inpatient Psychiatric Units

OBJECTIVE

An American Psychiatric Nurses Association (APNA) task force reviewed current staffing research to revise and update the 2011 APNA "Staffing inpatient psychiatric units" position paper and provide recommendations to the APNA Board of Directors on how psychiatric mental health (PMH) nurses might champion the staffing needs of inpatient psychiatric units.

METHODS

Current research on staffing and nursing practice in inpatient psychiatric units was reviewed as well as variables believed to influence staffing and nursing practice, such as consumer needs and workplace culture. Since current nurse staffing principles emphasize nursing value and how that value is connected to outcomes, the literature search included a focus on staffing and related patient outcomes.

RESULTS

PMH nurses are critical to the safety and quality of care in inpatient psychiatric units. However, there are little existing data on the relationship between staffing levels and even common adverse events such as staff injury and restraint of patients. Furthermore, there is scant research conducted on inpatient psychiatric units that informs optimal staffing models or establishes links between staffing and patient outcomes.

CONCLUSIONS

Consistent with current evidence, the universal use of a single method or model of determining staffing needs (e.g., nursing hours per, case mix index, or mandatory ratios) is not recommended. PMH nurses should champion systematic evaluation of staffing on their inpatient units against select patient, nurse, and system outcomes. A data repository of PMH nurse-sensitive outcomes is necessary to benchmark unit performance and staffing.

Rural-Urban Disparities in Quality of Inpatient Psychiatric Care

OBJECTIVE

Rural residents have higher rates of serious mental illness than urban residents, but little is known about the quality of inpatient psychiatric care available to them locally or how quality may have changed in response to federal initiatives. This study aimed to examine differences and changes in the quality of inpatient psychiatric care in rural and urban hospitals.

METHODS

This national retrospective study of 1,644 facilities examined facility-level annual quality-of-care data from the Inpatient Psychiatric Facility Quality Reporting program, 2015-2019. Facility location was categorized as urban, large rural, or small or isolated rural on the basis of zip code-level rural-urban commuting area codes. Generalized regression models were used to assess rural-urban differences in care quality (five continuity-of-care and two patient experience measures) and changes over time.

RESULTS

Rural inpatient psychiatric units performed better than urban units in nearly all domains. Improvements in quality of care (excluding follow-up care) were similar in rural and urban units. Rates of 30- and 7-day postdischarge follow-up care decreased in all hospitals but faster in rural units. Timely transmission of transition records was more frequent in small or isolated rural versus urban units (mean marginal difference=22.5, 95% CI=6.3-38.8). Physical restraint or seclusion use was less likely in rural than in urban units (OR=0.6, 95% CI=0.5-0.8).

CONCLUSIONS

Rural psychiatric units had better care quality at baseline (better follow-up care, better timely transmission of transition records, and lower rates of physical restraint use) than urban units, but during 2015-2019, follow-up care performance decreased overall and more in rural than urban units.

Effectiveness of Hospital-Based Interventions by Occupational Therapy Practitioners on Reducing Readmissions: A Systematic Review With Meta-Analyses

IMPORTANCE

Readmission to the hospital can lead to poorer patient outcomes and increased health care costs. The effect of occupational therapy interventions for adult hospitalized patients on readmission rates has not been previously evaluated.

OBJECTIVE

To systematically examine the published literature to determine the effects of occupational therapy interventions for adult hospitalized patients on readmission rates.

DATA SOURCES

Systematic search of five electronic databases was performed from database inception until May 2020, supplemented by citation and reference list searches. Study Selection and Data Collection: This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered prospectively; methodological quality of the included studies was assessed using the Downs and Black checklist. Meta-analyses were conducted with clinically homogeneous data; the overall body of evidence was graded for quality.

FINDINGS

Meta-analysis of 7 studies with 16,718 participants provided low-quality evidence that 1-mo readmission rates were reduced when adult patients hospitalized for general medical and surgical care received additional occupational therapy interventions compared with standard care. Subgroup analysis of 4 studies provided moderate-quality evidence that interventions focusing on the transition from hospital to the community were effective in reducing 1-mo readmissions to hospitals compared with standard care.

CONCLUSIONS AND RELEVANCE

Occupational therapy interventions can be effective in reducing readmissions among some adult hospitalized patient populations, including those admitted for surgery or management of acute medical conditions, with stronger evidence to support transitional care interventions. What This Article Adds: Occupational therapy interventions can be effective in reducing readmissions among adult hospitalized patients. There is a continued need for occupational therapy practitioners to understand their value and contribution to reducing avoidable readmissions to hospitals.