A pilot randomized control trial: testing a transitional care model for acute psychiatric conditions.

Area of Science:

• Psychiatric Nursing
• Health Services Research
• Transitional Care

Background:

• Individuals with serious mental illness (SMI) and co-occurring physical health conditions experience high rates of hospital discharge failure.
• The Transitional Care Model (TCM) is effective for elderly patients with physical conditions but unstudied in SMI populations.

Purpose of the Study:

• To evaluate the effectiveness of a TCM intervention delivered by a psychiatric nurse practitioner for patients with serious mental illness transitioning from hospital to home.

Main Methods:

• A randomized controlled trial involving 40 inpatients from psychiatric units.
• Intervention group received TCM for 90 days post-discharge; control group received usual care.
• Outcomes included service utilization, quality of life, and continuity of care.

Main Results:

• The intervention group had higher rehospitalization rates (p = .054) but improved continuity of care with primary care appointments (p = .023).
• Emergency room use was lower in the intervention group, though not statistically significant.
• General health improvements were observed in the intervention group but did not reach statistical significance.

Conclusions:

• A transitional care intervention is recommended for SMI patients.
• The model requires modification to a multidisciplinary team, including a psychiatric nurse practitioner, social worker, and peer support specialist.
• A team approach is essential for managing complex physical/mental health and social needs in this population.