Bridging the Gap: Impact of dedicated post-discharge services on readmission rates and emergency department visits for psychiatrically hospitalized youth

Abstract

Background: For psychiatrically hospitalized youth, discharge care coordination can reduce suicide risk and rehospitalization, but studies on effective interventions or programs are sparse. This study aimed to examine the impact of a dedicated post-discharge bridging service including case management and therapeutic supports on readmissions and emergency department presentations. Methods: This retrospective cohort study compared emergency department mental health visits (EDMH) and psychiatric hospitalizations in the 60 days before the hospitalization which included referral to the bridging service, and in the 60 days post-hospitalization. Results: This diagnostically heterogeneous group of 238 youth had a mean age of 14 years and were of similar racial and ethnic background as the broader inpatient population. There was a nominal decrease in hospitalizations (p = 0.251), and a significant decrease in EDMH (p < 0.001) in the 60 days following referral to this program compared to the 60 days prior. Further, the proportion of patients with at least one EDMH or hospitalization decreased significantly before and after linkage with this service from 42.4% to 27.3% (p < 0.001). Conclusion: Dedicated post-discharge bridging services including family-centered, flexible case management and therapeutic supports can reduce EDMH visits and potentially lower readmission for children and adolescents.

Keywords

Child and adolescent psychiatry inpatient hospitalization care coordination discharge planning readmission

Introduction

The transition from inpatient psychiatric hospital care to the community requires robust planning and coordination for youth, their caregivers, and clinicians. Mental health follow-up within 1 week of discharge reduces suicide risk in youth and is considered a best practice (Fontanella et al., 2020; National Action Alliance for Suicide Prevention, 2020). Aftercare also has been shown to reduce rates of rehospitalization by 32% (Cheng et al., 2017). Despite this, fewer than half of discharged patients connect with outpatient mental health services within the week after discharge, and only two-thirds find services within a month (National Committee for Quality Assurance, 2013). Readmission, in addition to being a commonly used quality metric, is a costly outcome and potentially distressing experience for youth, families, and clinicians.

Comprehensive discharge transition planning can promote safe movement from the inpatient to community setting, though studies on effective strategies are heterogeneous and limited (Chen et al., 2022). There are few reports of dedicated bridge programs, specifically designed and staffed to support children and adolescents and families as they transition from the psychiatric hospital to a lower level of care. The literature base is largely silent on effectiveness of these programs in reducing readmission and other adverse outcomes (Cameron et al., 2007; Cleverley et al., 2018; Drell, 2006). There is also limited research on these bridge programs in other fields of medicine. A randomized clinical trial of transitional care bridge services in older adults hospitalized to a medical ward found no improvement in activities of daily living for the intervention group (Buurman et al., 2016). A cardiac care bridge transitional care program for adults over 70 years old did not reduce hospital readmission or mortality in the 6 months after discharge (Jepma et al., 2021).

Despite the limited existing evidence base, there is purported benefit in clinical programs dedicated to supporting youth and families through the transitional period between inpatient hospitalization and the next step in treatment, which may be outpatient treatment, intensive outpatient or partial hospitalization programming, or admission to a residential treatment facility. Given the critical importance of the post-discharge period, there is a need to better understand how to effectively support youth and families as they leave the hospital with flexible, accessible, patient- and family-centered interventions. Limited outpatient resources, long wait times, and other barriers have challenged inpatient clinicians and families alike to follow best practice guidelines of accessing mental health care within a week following discharge. Hospitalized youth often have chronic mental health symptoms and challenges in multiple domains and will need ongoing interventions and support. Thus, there is a need for innovative services and care delivery models to support children and caregivers during this high-risk time period and beyond.

The demand for youth mental health services has been increasing for some time and is expected to continue to grow, accelerated by the COVID-19 pandemic (Binagwaho & Senga, 2021; Office of the Surgeon General, 2021). A shortage of psychiatrists and other mental health practitioners--more pronounced globally in low- and middle-income countries (Binagwaho & Senga, 2021), delays in diagnosis and access to care for youth with mental health treatment, and structural inefficiencies all compound this issue (McGorry et al., 2022). Thus, flexible, family- and patient-focused services, coupled with research to expand our understanding of effective and evidence-based interventions for youth at different stages in the care continuum, will be critical in meeting the growing demands of our field.

This study examines the patient characteristics and outcomes, specifically readmission rates, of a novel discharge transition program known as the Community Advocacy and Resource Engagement (CARE) Team. The CARE Team was created in late 2019 with an aim to provide short-term, post-discharge case management and therapeutic supports for youth being discharged from the Psychiatry and Behavioral Medicine Unit (PBMU), an acute-care psychiatric unit in Seattle Children’s Hospital in the United States with an average length of stay of approximately 10 days.

Methods

Participants

Psychiatry and Behavioral Medicine Unit clinicians, including psychiatrists, psychiatry trainees, advance practice nurses, mental health therapists, and case managers, referred patients to the CARE Team based on their subjective assessment that the youth was at elevated risk for readmission and/or needed short-term services as a bridge to longer-term treatment engagement. To maintain an inclusive and flexible approach, there were no strict inclusion or exclusion criteria for patients, with deference to the clinical judgment of the referring practitioner.

Procedure

Contact between the family and the CARE Team began either prior to discharge from the PBMU within 3 days post-discharge. Community Advocacy and Resource Engagement Team services were available to patients and families for 1 month, with opportunities to extend if needed to address outstanding case management needs. The team was composed of a family advocate/case manager and a mental health therapist and had a capacity of up to 20 patients at a time. Admissions to the team occurred on a rolling basis.

The CARE Team offered a range of services tailored to the individualized needs of each family. Patient/family phone contact was defined as brief phone discussions with goals of offering supportive contact, checking in on progress or status, problem-solving barriers, and relaying information. Clinician phone contact was brief phone discussions with clinicians to clarify availability and scope of services, relay information, and/or set up intake appointments. Care coordination involved more in-depth communication and facilitation or organization of services and supports, involving both the patient and their caregivers and representatives from these services, centered around the patient and family; at times this involved advocacy to insurance companies to cover out-of-network services. Community outreach was communication centered around existing mental health services, agencies, or clinicians in greater depth than clinician phone contact, with goals of building partnerships, sharing information on available clinical services, establishing standard practices for future communication and referrals, etc. Referrals involved researching and assembling appropriate specific treatment options and sharing these with the family. Therapy bridge involved brief individual or family psychotherapy, usually weekly or twice weekly for the duration of CARE Team involvement, with the patient/caregivers focused on safety and continued stabilization while awaiting linkage with a longer-term therapist. Med bridge was defined as an appointment or appointments with a psychiatrist for medication management follow-up while awaiting establishment of care with a longer-term practitioner.

These services were flexibly offered depending on the needs of the family, patient, and circumstances. For example, for a teenager with several pending referrals to residential treatment facilities, the therapist could provide weekly therapy while the case manager could follow up on referrals and coordinate admission to a residential program. For a child with autism spectrum disorder and disruptive behaviors, the case manager could coordinate treatment planning discussions between the new behavioral therapist, the inpatient team, and the pediatrician. In many cases, members of the team provided near-daily phone contact to parents and/or patients to provide support and coaching to use their safety plan while awaiting an intake appointment. Once patients established care with a clinician or program, the CARE Team signed off.

The CARE Team utilized tracking documents to record the duration of involvement with the team and services utilized. The first 85 patients’ caregivers were surveyed via phone call interview regarding satisfaction with the program several weeks after termination of service, using a five-point Likert scale to rate helpfulness of the program in connecting the child to longer-term treatment. Subsequently enrolled patient caregivers were not surveyed due to the loss of this staff resource. For the first 93 patients, CARE Team staff tracked which services they provided to patients and families; the same two team members determined which services were provided, rather than approximating this retrospectively from chart review, to optimally standardize how the service definitions were applied.

Investigators performed chart reviews of all CARE Team patients to determine additional demographic information including age at the time of service, sex at birth, gender identity, and racial and ethnic background. They also recorded the number of psychiatric hospitalizations and emergency department visits for mental health reasons (EDMH) in the 60 days prior to the hospitalization leading to CARE Team enrollment (referred to as the index hospitalization), as well as the 60 days after discharge from the hospital. The use of the medical record system Epic allowed the investigators to see records from all other hospitals who utilized Epic; Epic maintains 31% of the market share for electronic medical records and is the most widely used platform (Drees, 2021). Charts were also reviewed for referrals to the PBMU from outside hospital emergency departments within the 60 days prior to or after the index hospitalization as these were recorded in our medical records. Since the PBMU is the only hospital in the state who treats young patients or youth with autism, all inpatient referrals for these youth would be routed to this hospital.

The Institutional Review Board at Seattle Children’s Hospital approved this study. Statistical analysis was performed using IBM SPSS for Windows, version 27.

Results

Clinical characteristics

Between December 2019 and February 2022, the CARE Team worked with 238 patients. They carried a broad range of diagnoses including mood and anxiety disorders, psychosis, obsessive compulsive disorder, disruptive behavior disorders, intellectual/developmental disorders including autism, eating disorders, and post-traumatic stress disorder. Youth with autism spectrum disorder comprised 25% of the CARE Team population compared to 16% of the inpatient unit as a whole during this time frame.

Mean patient age was 14 years, with a range of 5–17 years and a mode of 13 years (n =40); the mean patient age for the entire inpatient population during this time frame was comparable at 13.4 years. The CARE Team patients were of similar racial and ethnic background as the entire PBMU population during this time, with 36% of the entire PBMU patient population and 37% of the CARE Team patients identifying as Black, indigenous, or persons of color (BIPOC). Of the youth in the study population, 20.6% identified as transgender or nonbinary, compared to 24% for the unit as a whole. Table 1 summarizes age, race/ethnicity, sex assigned at birth, and gender identity of the patient population.

Table 1.

Demographic characteristics of patients.

Race or ethnicity
White, not Hispanic/Latino		58%
Black or African American		11%
Hispanic or Latino		10%
Asian or Pacific Islander		8%
American Indian or Alaska Native		1%
More than one race		3%
Other		4%
Refused		5%
Age range
7y or under		2.9%
8 – 9y		5.5%
10–11y		11.8%
12–13y		27.7%
14–15y		26.4%
16–17y		26.4%
	F, %	M, %	Nonbinary/fluid
Gender identity	45.8	42.4	11.8%
Sex assigned at birth	63.4	36.6	n/a

On average, families each utilized 3.5 services; see Figure 1 for breakdown of services utilized. The mean length of service was 5.5 weeks. Caregiver satisfaction was 3.9/5 for the 85 patients who were surveyed.

Outcomes – Readmissions and ED visits

The total number of psychiatric admissions in the 60 days pre-index hospitalization and post-discharge were compared for the 238 CARE Team patients using paired sample T-test; the same calculation was done for EDMH visits pre- and post-discharge. There was a significant decrease in EDMH visits, from 113 to 47, and a nominal decrease in hospitalizations, from 75 to 61; Table 2 shows these findings.

Table 2.

Total EDMH and hospitalizations for CARE Team patients.

	60 days pre-index admission	60 days post	Percent Change	T(DF)	SD	p
Psychiatric hospitalizations	75	61	−18.7%	1.152 (237)	0.788	0.251
EDMH visits	113	47	−58.4%	4.708 (237)	0.909	<0.001

Note. EDMH = emergency department visits for mental health reasons; CARE = Community Advocacy and Resource Engagement.

In the study group, 101 of the 238 youth (42.4%) had at least one emergency department visit for a mental health crisis (EDMH) or psychiatric hospitalization in the 60 days pre-index hospitalization; this decreased to 65 youth (27.3%) in the 60 days post-discharge. McNemar’s test showed a statistically significant difference in these groups (p < 0.001). By comparison, 28.3% of all PBMU patients in a similar time frame had at least one EDMH visit or psychiatric hospitalization at our hospital alone in the 60 days post-discharge; this differed from the CARE Team subpopulation before index hospitalization (p = 0.001) with more CARE Team patients having an EDMH visit or hospitalization but was statistically equivalent post-discharge (p = 0.918).

Discussion

This study of a novel discharge bridging service demonstrated statistically significant reductions in EDMH visits for mental health reasons, and a nominal reduction in psychiatric hospitalizations in the 60 days after discharge, compared to the 60 days prior. Further, the proportion of youth with any EDMH visits or hospital stays decreased significantly in the 60 days post-discharge. The CARE Team patients had a greater proportion of youth with at least one prior EDMH visit or psychiatric hospitalization than the unit as a whole before CARE Team involvement; after discharge with CARE Team services, this metric was not statistically different than the general inpatient population.

This patient population was diagnostically heterogeneous and had moderate to severe mental illness and psychosocial stressors, so it is not unexpected that psychiatric hospitalizations were only modestly impacted. This group of patients was identified by the treatment team as being at an elevated risk for readmission, so even a small reduction in readmissions rate, and a reduction to a level consistent with the general inpatient population, is noteworthy. Youth with ASD were disproportionately referred to the CARE Team, suggesting particular challenges in care coordination and discharge planning for these patients, who often require multi-system supports and resources. Our study was not adequately powered to examine outcomes for specific subsets of the CARE Team population, such as youth with ASD, though future study may explore which groups most benefit from such services.

The reduction in ED visits suggests that these youth and their families benefitted from having an available, flexible, supportive team to help navigate challenges that did not quite reach the threshold of imminent danger, situations that may have led to an ED visit without the availability of such professionals. With the support of the CARE Team, this high-risk group had reductions in their 60-day readmission and ED presentation rate that brought them in line with the general inpatient population. This was achieved largely through care coordination and phone support; fewer than 10% of patients required a bridge therapy appointment, either in person or via tele-health. This suggests the importance of case management and flexible support in the potentially tumultuous and stressful time after discharge from the hospital.

A limitation of this study is the lack of a true control group. Since the CARE Team patients were a higher-risk subset of the entire inpatient population, we utilized paired samples within the same population by comparing psychiatric hospitalizations and EDMH visits in the 60 days prior to the index hospitalization with the 60 days after. These patients were selected for the CARE Team because they were assessed to be at a high risk for readmission or had some outstanding post-discharge need. In light of the COVID-19 pandemic, which began a few months after the CARE Team began, and its impact on mental illness and the availability of mental health services for youth, performing a randomized trial in which half of referred youth got treatment as usual rather than this needed support was ethically questionable. The use of paired samples was selected as a way to balance the need for a comparison group to evaluate outcomes with the treatment needs of this vulnerable patient population during an unprecedented public health crisis.

It is possible that patients in this cohort had EDMH visits and admissions to other psychiatric hospitals in the region, as not all facility’s records were accessible through our platform. However, consistent methodology was used for both time periods. Thus, though there may have been events not visible to the research team, these events were equally likely to occur before and after the index hospitalization. The readmission data for the unit as a whole included admissions and EDMH presentations at our hospital only, so the CARE Team data was more comprehensive by using the additional data from other hospitals. Since the PBMU is the only unit in the state who treats certain patient populations, there is reasonable confidence that all referrals for these patients were recorded in the medical record.

Another limitation is the broad, nonspecific definitions of the interventions. For example, “care coordination” potentially encompasses a wide array of activities and outcomes. This could create challenges both in attempting to replicate a successful attempt at this activity, and in understanding what specific elements (behaviors or outcomes) were the critical ones. On the other hand, allowing a flexible, youth- and family-focused approach can be seen as a strength of this service.

The financial implications of this type of service are an important consideration. We saw reductions in emergency department visits and hospitalizations, both of which are costly and resource-intensive interventions. In our system, the only billable CARE Team service was therapy or medication management appointments, and a small minority of patients received these. Replicating this service would require an initial financial investment in staffing resources and motivation to save costs beyond what is reflected in billable income. Further investigating and advocating for creative funding mechanisms will be needed to implement and sustain such a program.

An area of future study involves more in-depth analysis of which patient groups benefit most from this service, or even which components of this service. Further development of this program may involve dedicated integration with other clinical programs that provide longer-term treatment and expanding the team in order to serve patients referred from other settings including primary care clinics, emergency departments, and more.

An important acknowledgement is that this program was created as a novel way to fill gaps in a mental healthcare system that is not adequately meeting the needs of patients and families. Youth with severe, acute mental illness requiring hospitalization need a flexible, supportive continuum of care that provides a range of services and supports with varying intensity over time, especially in the high-risk time following hospital discharge. In an ideal world, the CARE Team would not be needed because there would be a robust network of Partial Hospitalization Programs and/or Intensive Outpatient Programs, residential treatment facilities, wraparound care, family supports, and other services ready to help children as they transition out of the hospital, or all patients and families would have access to services like the CARE Team to complement other robust therapeutic interventions rather than as a standalone stopgap.

Footnotes

Acknowledgements

The PBMU CARE Team is funded by a generous donation from Seattle Children’s Guild Association as part of their Funding Hope Award. We also would like to acknowledge Kathy Brewer, LICSW and Rand Goldman, LMFT for their support of the CARE Team.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Approved by Seattle Children’s Institutional Review Board, identifier STUDY00002753

ORCID iDs

Shannon Simmons

Alysha Thompson

Author biographies

Shannon Simmons, MD, MPH Medical Director of Inpatient and Acute Mental Health Services, Seattle Children's Hospital, Associate Professor, Department of Psychiatry and Behavioral Sciences, University of Washington.

Chelsea Noble has been working at Seattle Children's Hospital for 2 years. Seattle Children's Hospital is part of the Medical & Surgical Hospitals industry, and located in Washington, United States.

Kristen Arquette M.Ed LMFT SUDP, Mental Health Therapist, Seattle Children's Hospital.

Alysha D. Thompson, PhD – Clinical Director, Psychiatry and Behavioral Medicine Unit, Seattle Children's; Associate Professor, Psychiatry and Behavioral Sciences, University of Washington.

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