Running head: EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 1

Effects of Follow-Up Psychiatric Care on Hospital Readmission

Stephanie Knight

Brigham Young University – Idaho

NURS 420

Brother Butikofer
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 2

Effects of Follow-Up Psychiatric Care on Hospital Readmission

Background

Psychiatric readmission rates are high. The psychiatric readmission rate in America and

in Canada is thirteen percent and, in Europe, the readmission rate is twenty-eight percent

(Donisi, Tedeschi, Salazzari, & Amaddeo, 2013). These readmission rates are within thirty days

of the initial discharge to the psychiatric hospitals from which patients were discharged. These

findings were taken and analyzed from patient records from four different hospitals to calculate

these percentages. Such studies have been conducted for decades and have shown similar results.

Non-psychiatric-based readmission rates are lower than when the patient has a

psychiatric diagnosis. Because most hospitals calculate readmission rate specific to diagnosis, it

is difficult to quantify an exact comparison between physical and psychiatric morbidity

readmission rates. However, according to a study done on over twenty-seven million inpatients

in traditional hospitals, the top cause of readmission to inpatient care within seven and thirty-day

periods are mental disorders (Fingar, Barrett, & Jiang, 2017). For every one-hundred hospital

admits, nine psychiatric patients are readmitted after seven days and about twenty-three

psychiatric patients are readmitted after thirty days. Comparatively, congestive heart failure

(CHF) patients have a seven-day return rate of approximately seven readmits per one-hundred

admits, and twenty-three patients for every 100 admits who are readmitted within a thirty-day

period (Fingar, Barrett, & Jiang, 2017). CHF readmission rates within thirty days are higher than

psychiatric readmissions by a scant point-three percent, and seems to be the only physical

condition that seem to rival psychiatric readmission rates.

Both adults and adolescents are being readmitted at high rates when a psychiatric

component is involved. A study done by Heslin and Weiss (2012) found that one in four people
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 3

are diagnosed with a mental illness. Up to fourteen percent of adults eighteen and older were

likely to be readmitted after thirty days for mood disorders, and children seventeen and younger

had a nine percent readmission rate. For children between one and seventeen years of age,

mental illness was the most common cause for hospitalization and rehospitalization. Between

nine and twenty-two percent of psychiatric patients of all ages were found to be readmitted after

thirty days while non-psychiatric readmission rates fell between four and fifteen percent.

Significance

Researchers speculate about the reason for psychiatric readmissions, but are unsure of the

exact cause. Donisi, et al. (2013) have found medicine non-compliance to be a massive

contributor to readmission, but it is not the only one. Many inpatients struggle with

comorbidities, or co-existing problems, that make treatment or continuation of care difficult. For

example, substance abuse can either trigger latent mental health issues or exacerbate an existing

one, often resulting in first-time or repeated hospitalizations. Some inpatients are homeless or are

financially unstable, thus decreasing the likelihood of medication compliance or follow-up care.

There are many reasons speculated about why patients with psychiatric problems are readmitted,

but the exact reason is unknown.

The success of inpatient treatment is often speculated by readmission rates. Policy

makers for healthcare facilities do this as an easy way to quantify readmissions and their

correlating spending costs. Such quantifications are also an easy way to identify problem areas

(Fingar, Barrett, & Jiang, 2017). When these numbers are high, the accuracy of diagnoses, the

quality and coordination of cares, and the time of discharge are questioned (Donisi, et al., 2013).

Readmission could mean premature discharge, an inaccurate diagnosis, insufficient time spent

stabilizing the patient’s medication or condition, or poor continuity of care between inpatient and
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 4

outpatient centers (Donisi, et al., 2013). Either way, readmissions result in high costs to the

psychiatric hospital and related organizations which run them, and to readmitted patients.

The unknown cause of psychiatric readmissions is causing a decreased quality of life for

those seeking constant medical attention. When the same patients are readmitted, new patients

are not receiving needed treatment. A study done on the 3.4 million people living in North

Carolina showed that an average of twenty-eight adult beds are available to psychiatric patients

per one-hundred-thousand people (Fuller, 2016). Further studies estimate that at least thirty-nine

beds are needed per one-hundred-thousand people in a population. Many states, however, lack

the number of beds necessary for sufficient population treatment. This means that patients end up

waiting for psychiatric care that may arrive after days to weeks of waiting or not at all.

Readmission rates can also be used to measure quality of a patient’s life (Varcarolis, 2017).

Unsuccessful psychiatric treatment may be used to indicate inability or difficulty to lead a self-

fulfilling and independent life. Psychiatric hospital readmission rates are high, and the cause of

readmission is unknown.

The Transtheoretical Model

The Transtheoretical Model (TTM) implements five precognitive steps to change:

precontemplation (denial of the problem), contemplation (reluctance to change), preparation

(small steps to change), action (committing to the change), and maintenance (change lasting for

six months or more). These steps tend to be cyclic, as a subject can regress to previous steps and

begin again. Within these stages are two processing groups that affect goal progression and

regression (Rossi & Redding, 2008).

There are two major processes that work within TTM’s five stages (Rossi & Redding,

2008). Consciousness raising (understanding and awareness of malady), dramatic relief (feelings
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 5

of susceptibility to malady), environmental reevaluation (understanding how surroundings affect

the individual), self-reevaluation (comprehending how malady affects self-image), and social

liberation (understanding of social norms and healthier options) are found in the experimental

process. The second processing group, behavioral, includes the following: contingency

management (reinforcing goal-oriented behaviors), counterconditioning (replacing negative

behaviors for positive), stimulus control (removing negative stimuli, and seeking positive

environments), and self-liberation (adhering to change) (Rossi & Redding, 2008).

Link Between the Transtheoretical Model and Psychiatric Readmission Rates

Psychiatric hospitals use TTM by controlling patient stimuli and providing social support

from staff and other inpatients. This capitalizes on TTM’s environmental control process to

promote a patient’s desire to adhere to healthier practices in their lives beyond the hospital.

However, such maintenance of changes is not always preserved. A study by Ehrenreich et all.

(2012), revealed only thirty-three percent of psychiatric inpatients received recommendations for

follow-up care upon discharge, and only fifty-seven percent of that sample received follow-up

care. Additionally, multiple studies have shown that medication compliance is often limited at

best. It is also regarded as the greatest factor in readmission rates. Seung Yup Lee et al. (2015)

found that seventy percent of schizophrenic patients without outpatient follow-up care were

noncompliant with their medications. Five years post-hospitalization, eighty-two percent of these

patients experience relapse and possible readmission (Lee et al., 2015).

TTM is most commonly used in tandem with substance abuse disorders, but can be used

to change habits in general. Prochaska et al. (2014) conducted an experimental study on two-

hundred-and-twenty-four volunteer inpatients from psychiatric hospitals who smoked a pack of

cigarettes daily. The control group received standard hospital cessation treatments, and the
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 6

experimental group followed TTM’s five steps to change. Fifty-six percent of patients who

received traditional hospital cares were readmitted. In contrast, only forty-four percent of

patients who received TTM interventions were readmitted (Prochaska et al., 2014). While studies

in smoking cessation and TTM are limited, the results look promising for further studies. In this

study, TTM behavioral and environmental processes will be used to evaluate causes in

discharged patient environment, community support, outpatient follow-up cares, and individual

attitudes that may lead to increased readmission rates.

Research Methods

Continued outpatient care for discharged psychiatric inpatients will decrease hospital

readmission by bolstering patient awareness of self and surrounding environment. Increased

patient awareness and knowledge will decrease psychiatric hospital readmission rates.

Understanding patient behaviors and environment on discharge may help identify factors that

decrease adherence to TTM (Rossi, 2008). Identified behaviors that correlate with high

readmission rates may be used to individualize patient teaching and provide additional patient

support upon discharge as may be required.

Research Design

This will be an exploratory, mixed-methods design. An exploratory study seeks to

explain a phenomenon or event that is not already clearly understood (Statistics Solutions, 2017).

Exploratory studies are also used to determine effective designs for future studies. It often starts

with a quantitative study, then implements the use of a qualitative study. A mixed-method study

design uses the second study to provide further insight to the first study. In the event of an

explanatory mixed-method design, a quantitative study is done first to evaluate a phenomenon. A

qualitative follows the quantitative to provide deeper insight to the problem presented in the
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 7

quantitative study. Because data regarding the cause of high psychiatric readmission rates is

limited and inconclusive, an explanatory mixed-method design will provide multiple angles for

data collection, thus expanding sources of knowledge for further analysis. Furthermore, a broad

view followed by a patient-centered qualitative view may connect causes for readmission rates

that have been previously overlooked.

Research Population

The research population for the quantitative study portion would originate from four,

randomly selected, psychiatric hospitals across the United States to determine rates of

readmission within thirty days between 2015 and 2017. These records would be used to calculate

an overview for readmission rates specific to these areas and how they compare to other

psychiatric hospitals in the States. The hope for this part of the study is it would uncover

percentages of outpatient care and correlating readmission rates.

The population for the qualitative research study would include follow-up interviews

with twenty patients who were readmitted after thirty days of discharge, and twenty patients who

remained discharged longer than thirty days from each of the four hospitals used. The research

population will be discharged and readmitted psychiatric patients with chronic conditions

between 2015 and 2017. Between the quantitative and qualitative steps of this study, it is hoped

to find characteristics of individuals and of their discharged environments that impact psychiatric

readmission rates.

Data for acute patients who did not receive inpatient care, pediatric inpatients, and

inpatients who were admitted to multiple facilities instead of one, will be excluded from this

study. These sub-populations are excluded to prevent overlapping data, and to focus on

populations that have the highest rate of psychiatric readmission. Patients with chronic
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 8

conditions who have been readmitted to the same psychiatric hospital more than once, patients

over the age of eighteen, and patients who have been treated as an inpatient in a single facility

once and have not been readmitted since treatment, will be included in this study.

Methods and Measurement

This research will be conducted by using two major steps. First, the quantitative research

will be conducted to assess the situation from a broad perspective. This will identify how

readmission rates differ between psychiatric hospitals across the States within the last three

years. Readmission rates from these four hospitals will be determined by patient records and

previous facility readmission statistics. With an overview specific to these four facilities,

qualitative studies in the form of interviews may be conducted with patients on a volunteer basis.

Patients will be assessed for the number of times they were readmitted, and what factors they

perceive contributed to their hospital readmissions or lack thereof. Factors of interest include

community support, social support, socioeconomic status, access to continued care, and personal

beliefs and understanding of their illness and corresponding treatments. A new scale may need to

be implemented to promote report consistency.

Once the data is collected from all willing participants, the qualitative results will be

measured against quantitative readmission rates to determine the most common correlating

factors for readmission rates. With enough data, such patterns should be more easily identifiable.

It is unlikely the exact cause of high psychiatric readmission rates will be identified from this

study alone. The purpose of this study is to provide a solid basis for future studies by revealing

factors that require additional attention. Because findings of this research may impact hospital

policies, results will be made available to psychiatric hospitals, policymakers, healthcare

workers, and other researchers for further assessment.

EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 9

Ethical Considerations

This study will be using participants that have received inpatient psychiatric care within

the last two years. These participants are of vulnerable population, as inpatients often feel

coerced to participate in studies (Grove, Gray, & Burns, 2015). To protect these rights, the

researcher will outline the patient’s rights and affirm that the patient’s treatment will not be

impacted by declining or accepting participation in the study. Additionally, participants will be

considered for the study on a volunteer basis.

Persons with mental illness may be unable to provide informed consent. These patients

will be protected under beneficence, which enforces the researcher to do no harm to study

participants (Grove et al., 2015). Patients involved in this study will have their rights maintained

and to be treated as individuals. It is the patient’s choice to participate and will not be coerced or

swayed by researchers or healthcare providers to participate. These persons will be alerted of any

risks or benefits that may influence them or their families while they are involved in this study.

Patients will also have the option to withdraw from the study at any point if they deem such

action necessary for any reason.

This study will be using psychiatric inpatient records between the years of 2015 and

2017. Privacy and confidentiality may be breeched in accessing such records (Ozair, 2015).

Subject and facility privacy must be maintained to protect individual confidentiality. Records

obtained for the quantitative study will be done by informed patient consent when appropriate, or

through records made available for study by state laws. For patients who are mentally or

physically unable to provide informed consent for themselves, a direct power of attorney’s

informed consent may be applied instead. Informed consent must be given by participants after
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 10

receiving education on what the study will pertain. Additionally, patients who participate in the

qualitative portion of the study will maintain anonymity to protect their privacy.

Annotated Bibliography

Arnold, M. E., Buys, L., & Fullas, F. (2015). Impact of pharmacist intervention in conjunction

with outpatient physician follow-up visits after hospital discharge on readmission

rate. American Journal of Health-System Pharmacy, 72(S1), S36-S42.

doi:10.2146/sp150011

These three authors are pharmacists from Sioux City, Iowa. They collaborated to produce

a qualitative prospective study. The intended audience for this article are hospitals with

pharmacies and pharmacists. The research study was conducted to determine the impact

of pharmacist follow-up appointments on medication compliance for discharged hospital

patients. In the study, physicians initiated follow-up with discharged patients greater than

or equal to the age of fifty. Demographics, drug therapies, patient medication histories,

and time necessary for pharmacists to review the needed information. Ninety-eight

patients of the two-hundred-thirty-six patients received the pharmacist intervention and

were followed in a longitudinal study to determine effectiveness. They found that patients

who received follow-up care from a pharmacist experienced decreased readmission rates

when compared to physician-only follow-up cares. A strength of this study is the increase

of care coordination and communication between healthcare workers. A weakness of this

study is that it was done in an outpatient center and may not apply with many hospitals.

This study is useful to the nursing practice by promoting patient diagnoses, limiting drug

errors, and increasing medicine compliance. This article links to the research problem by

discussing the importance of follow-up care specific to medication compliance.

EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 11

Diplock, G., Ward, J., Stewart, S., Scuffham, P., Stewart, P., Reeve, C., & ... Maguire, G. (2017).

The Alice Springs Hospital Readmission Prevention Project (ASHRAPP): a randomised

control trial. BMC Health Services Research, 171-11. doi:10.1186/s12913-017-2077-7

These eight authors are health care providers from various colleges and research facilities

in Australia. This article is appropriate for healthcare workers in hospitals and outpatient

centers. The authors collaborated on this qualitative randomized control experiment to

evaluate the results of effective transition to outpatient care on hospital readmission rates.

Patients meeting inclusion criteria are separated into two groups. The first group is the

experimental group, which receives the new hospital to outpatient transition

interventions. The second group is the control group, who receives current hospital

discharge interventions. The study includes adults over the age of eighteen who have had

four or more hospital admissions in the last twelve months. Patients expecting or under

current end of life care are excluded. There are many tables that clearly express the

procedure of the study and its requirements. This study found that increased hospital

involvement in transitioning patients to outpatient care experienced decreased hospital

readmissions. This is the first study to evaluate tridimensional healthcare. A weakness of

this study is that it is unclear if this study can be applied to low socioeconomic patients in

remote settings. Its strength lies in its focus for high readmission risk patients. Nurses can

use the results of this study to guide their discharge teaching to maximize patient follow-

up care and satisfaction. This study relates to the research problem through insights to

chronic health hospital readmissions and the effects of transitional care.

EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 12

Herrin, J., St. Andre, J., Kenward, K., Joshi, M. S., Audet, A. J., & Hines, S. C. (2015).

Community Factors and Hospital Readmission Rates. Health Services Research, 50(1),

20-39. doi:10.1111/1475-6773.12177

These six authors are healthcare researchers from various United States organizations

such as Yale University, Navigant Consulting, and the Commonwealth Fund. This article

is intended for use by hospital doctors and administrators. The authors collaborated in

this observational, qualitative, hierarchical linear study to determine the effect of

community factors in hospital readmission rates. This study compiles the thirty-day

readmission rates for patients discharged from hospitals between July 1, 2007 to June 30,

2010 with a diagnosis of heart failure, pneumonia, or myocardial infarction. These

reports came from the American Hospital Association (AHA), Annual Survey Database

(ASD), Health Resources and Services Administration’s Area Resource File (ARF), and

Nursing Home Compare (NHC). Factors include patient socioeconomic status, retirement

home healthcare, pressure sores, and access to hospitals. The study found that community

factors answered fifty-eight percent of readmission rates. This study assess data from

four-thousand and seventy-three hospitals, a strong sample size. A weakness of this study

is its specificity to heart and lung diseases. Nurses can use this study to guide patient

teaching based on patient ability and access to healthcare facilities, and to advocate for

adequate outpatient healthcare. This article relates to the research problem by assessing

effectiveness of community cares.

Vigod, S. N., Taylor, V. H., Fung, K., & Kurdyak, P. A., (2013). Within-hospital readmission:

An indicator of readmission after discharge from psychiatric hospitalization. Canadian

EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 13

Journal of Psychiatry, 58(8), 476-81. Retrieved from https://search-proquest-

com.byui.idm.oclc.org/docview/1429243945?accountid=9817

These four authors are colleagues from the University of Toronto. This study is

appropriate for psychiatric hospital administrators and healthcare providers. The authors

collaborated to compile and assess qualitative administrative data sources to answer the

following question. The research study was conducted to assess the accuracy of using

general readmission rates compared to using same-hospital-readmission rates to

determine healthcare quality for psychiatric patients. Anonymous patient records,

demographics, and discharge information of psychiatric patients in Ontario were gathered

through the databases of the Institute of Clinical Evaluative Sciences (ICES), the Ontario

Mental Health Reporting System (OMHR), and the Canadian Institute for Health

Information-Discharge Abstract Database (CIHI-DAD). Transfers were not counted as

readmissions and patients who had no administration records attached to their discharge

information was excluded. They found that readmission rates were smaller for thirty and

ninety-day readmission rates when evaluating same-hospital-readmission rates. A

strength of this study is its large sample size, roughly thirteen-point-five million people.

A weakness is that this study may not apply to systems that do not implement universal

healthcare coverage. Nurses may benefit from this study by recognizing characteristics in

patients that correlate to high readmission rates and adjust their interventions as needed to

decrease readmission. This article relates to the research problem by discussing rates of

psychiatric readmission based on multiple patient descriptors.

EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 14

Implications

Nursing Knowledge

Further research into psychiatric readmission rates may uncover patterns or behaviors

that contribute to high readmission rates or the absence thereof. Factors that may be involved

include emotional and social barriers to individual success for discharged inpatients. Results may

find that people who are readmitted seek social and emotional support from hospitalization

because there is a lack of it in their life beyond the hospital. There are cases in which patients

nearing discharge bodily collapse in, what healthcare providers interpret as, an attempt to prove

they still require hospitalization. Aside from lacking a home to return to, psychiatric patients may

suffer a lack of social or community support upon discharge. Mental health, particularly

psychiatric hospitalization, is generally viewed with trepidation and uncertainty by many

community members. This stigma and potential for absent social support may leave patients

feeling isolated and falling back onto old coping mechanisms that contributed to their initial

hospitalization.

Nursing Theory

The Transtheoretical Model (TTM) views change as a cyclic process that depends on an

individual’s desire to change (Rossi & Redding, 2008). This study further supports TTM by

showing that patient progression to maintain healthcare changes is reliant on view of self, views

of society, and environmental stimuli. However, this study adds the idea that socialization is

essential to maintain behavioral changes. Avoiding stimuli that invokes old behaviors is not

enough, especially since discharged patients often lack the social support needed to maintain
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 15

new, healthier habits. Providing this positive support will increase a patient’s likelihood to

follow through with self-cares and obtain self-liberalization.

Nursing Practice

Nurses can now provide effective care and teaching for psychiatric patients during

hospitalization, discharge, and outpatient cares that will last the patient longer than thirty days.

Discharge teaching will become more specific to individual a patient’s physical, emotional, and

social needs outside of the hospital. Not all patients have a place to live, which requires nurses,

social workers, and other healthcare professionals, to coordinate cares with another facility such

as a group home or homeless shelter. Other patients may lack family to support and care for

them. A group or assisted living facility may also benefit these patients, but may not be practical

long-term depending on the patient’s resources. For patients of low socioeconomic status that

lack social support, a peer could be assigned to assist the patient in readjusting to daily life and to

decrease the patient’s feelings of estrangement. One goal of psychiatric patient care is for the

patient to achieve independence. To reach this, nurses need to advocate for discharged

psychiatric patients to be able to meet individual needs beyond the hospital walls.

Improve Patient Care

Personalizing discharge teaching to physical, mental, and financial needs of individual

patients will promote quality of care and life. Patients who have basic needs met are more likely

to succeed in long-term self-care maintenance. Each patient has different needs and struggles that

must be faced in the world outside of the hospital. Additionally, personalizing patient needs will

promote patient adherence to the healthcare plan and discharge teachings.

EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 16

Increasing patient and healthcare professional involvement in converting to outpatient

cares will promote cost-effective care by reducing the repeated need for readmission.

Maintenance of patient needs beyond the boundaries of the hospital will allow discharged

patients to pay lower fees than those associated with psychiatric hospitalization. Hospitals are

then enabled to provide cares for new patients instead of repeating care for a patient that is

unable to care for themselves after discharge.

Maintaining contact with discharged patients will improve safety. Discharge is a delicate

time for psychiatric patients as it removes them from a controlled, supportive environment, and

returns them to daily life. Suicide attempts are likely to occur during this transition. However,

such attempts could be reduced by maintaining support. This can be done with peer support,

community education, group homes, outpatient facilities, and telehealth calls.

Recommendations

Without the known cause of psychiatric readmission rates, further research from multiple

angles is necessary. More data comparing psychiatric versus physical hospital readmission rates

may provide insight to differences in how psychiatric and physical morbidities are treated during

hospitalization and outpatient care. Longitudinal qualitative studies may provide comparison of

readmission rates over the span of a lifetime between hospitalization and outpatient cares.

However, a longitudinal quantitative study may provide deeper insights to patient views on

continuity of cares. Such a study might find that psychiatric adherence is less likely to occur in

psychiatric patients due to lack of understanding, denial of need for care, or concerns regarding

societal stigma regarding cares. The population would be increased to compare sufficient

numbers for physical and psychiatric morbidities.

EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 17

Increased communication between patients, inpatient facilities, and outpatient facilities is

encouraged, as seen by this study. Continuity of care and an increased awareness of individual

patient needs must be considered to promote quality of care by individualizing discharge

teaching. This study can be used as a guideline for facilities to assess effectiveness of

communication between facilities of varying disciplines. Furthermore, increased communication

with the patient themselves provides greater insights to the needs they may have upon discharge,

and any views on their own health that may decrease compliance with continued care plans.

The results of this study may be used to guide the content of community education

regarding psychiatric patients and mental health. Increased understanding from society may

decrease the risk for social stigma, and foster a community of understanding and support. It may

also provide opportunities for peer support programs to be initialized in multiple areas. Such

support may allay discharged psychiatric patient apprehension while rejoining society, smooth

the transition, and increase the likelihood discharged patients will seek help from the community.
EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 18

References

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influencing early readmission to acute psychiatric wards: Implications for quality-of-care

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Ehrenreich, M. J., Robinson, C. T., Glovinsky, D. B., Dixon, L. B., Medoff, D. R., & Himelhoch,

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Fingar, K. R., Barrett, M. L., & Jiang, H. J. (2017, October). A Comparison of All-Cause 7-Day

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EFFECTS OF FOLLOW-UP PSYCHIATRIC CARE 20

Journal of Psychiatry, 58(8), 476-81. Retrieved from https://search-proquest-

com.byui.idm.oclc.org/docview/1429243945?accountid=9817