A metropolitan hospital system has developed and implemented a transition-of-care program focusing on patients with mental illnesses and high risk for hospital readmissions or emergency department visits. Currently, the transition period between care settings creates a state of vulnerability for patients and their caregivers. Poor care coordination negatively affects patient outcomes and results in a major economic burden. Patients with mental illnesses are particularly sensitive to transition-of-care issues including confusion about which medications to start and stop. This program aims to design, implement, and evaluate interventions to improve care transitions at 3 hospitals for individuals with a primary or secondary psychiatric diagnosis. In the inpatient setting, the clinical pharmacist, nurse practitioners, and social workers collaborate to identify medication-related problems. After patients are discharged from the hospital, nurse practitioners, the clinical pharmacist, and educators follow up with patients for 30 days via home health aide visits and telephone calls. Evidence-based tools and assessments are used to drive the program's interventions. From June 2014 to September 2014, 770 patients were identified as high risk. Readmissions data are pending. The patient outcomes data will fill the gap in the literature with essential information on transition-of-care issues within the mental health population. This program has implications to affect health care policy because it uses multiple evidence-based practices with the ultimate goal of decreasing economic burden for health systems and patients. New pharmacist roles in transition of care may emerge from this program.

Transition of Care

The transition phase from one care setting to another increases the risk for adverse events and preventable hospitable readmissions and emergency department (ED) visits. With transition of care, there are changes in medications, laboratories, and possibly even diagnoses. Close to the time of discharge from a health care setting, patients and caregivers are inundated with information on medications, side effects, and care instructions. Interventions used to improve transfer of care between settings serve to empower patients and caregivers and to ensure continuity of care.1  A report from the Institute of Medicine2  highlights that the United States health care system is decentralized and complex, failing to efficiently use the strengths of health care professionals. Poor care coordination negatively affects patient outcomes and results in major economic burden. In 2011, inefficient transition of care yielded $25 billion to $45 billion in wasteful expenditures through preventable hospital admissions and complications.3 

The complex needs of patients with mental illnesses and substance-abuse disorders necessitate improved transitions of care. In a study of patients who had experienced an acute coronary syndrome, patients who were depressed were more likely to exhibit nonadherent behaviors, including medication nonadherence for secondary prevention of acute coronary syndrome.4  The poor care-coordination practices in combination with debilitating symptoms of mental illness may result in patient confusion about medications and a lack of motivation to attend follow-up appointments. A report by the Texas Health and Human Services Commission (HHSC)5  found that, in 2011, bipolar disorder, schizophrenia, and major depressive disorders were among the top 5 severity-adjusted, diagnosis-related groups, by volume, for readmission in Texas. This same report found that patients admitted with surgical or medical conditions with a secondary diagnosis of major mental health or substance-abuse disorders were 83% more likely to be readmitted. Although health care professionals provide pertinent medical information to patients on discharge, the information is not patient centered and rarely provides ways to address symptoms, manage medications, and methods for answering ongoing health concerns.3 

Posthospital Medication Discrepancies

One of the major postdischarge issues is medication-related discrepancies, including patient confusion about which medications to stop and start. Coleman and colleagues6  found that 14.1% of patients discharged home experienced at least one medication discrepancy. In that study, common postdischarge medication discrepancies were nonintentional nonadherence, financial barriers, intentional nonadherence, incomplete/inaccurate/illegible discharge instructions, conflicting information from different sources, and duplicate prescribing. Additionally, it found that patients with at least one medication discrepancy (14.3%) had a significantly higher 30-day readmission rate compared with those without any medication discrepancies (6.1%). Other medication-related issues may include poor recall of discharge instructions, discharge medication-reconciliation errors, and adverse effects at home.

Transition-of-Care Programs

Health systems develop interdisciplinary transitional care programs, such as the Better Outcomes by Optimizing Safe Transitions (BOOST) program (Philadelphia, PA), to smooth transitions from hospital to home.7  These programs consist of pharmacists, nurses, social workers, and other health professionals serving to address transitional care issues. Research on transitional care for patients with primarily chronic physical conditions, such as heart failure, support its effectiveness in reducing ED visits or readmissions for a 30-day period. A 2013 study8  demonstrated that patients who received transition of care were 20% less likely to experience a readmission during the subsequent year. Although transition-of-care programs for patients with physical conditions exist, there are no such published cases, to our knowledge, on programs designed to serve patients with mental illnesses. A transition-of-care program with close postdischarge follow-up may benefit patients with mental illness through psychoeducation, support, and proactive discharge planning.

Purpose

To address the specific transition-of-care needs for patients with mental illness, Houston Methodist Hospital (HMH) developed the Behavioral Health Transition of Care Program. The remainder of this article describes the innovative program and the role of the clinical pharmacist as it relates to the interdisciplinary transition-of-care team. This program aims to design, implement, and evaluate interventions to improve care transitions at 3 HMH-system hospitals for individuals with a primary or secondary psychiatric diagnosis. The overarching goal is to improve the transition from hospital to home over 4 weeks by providing patients with tools that empower them to manage their conditions. Through the program's work, the hope is to put the concept that “recovery can occur even though symptoms reoccur” into action.9  As the program is in its early stages, its specific aims are to (1) establish a baseline for readmissions, (2) reduce readmissions by 20% below the baseline by 2016, (3) discharge 60% of the patients at high risk for a hospital readmission or ED visit with customized-care plans, (4) screen 60% of the high-risk patients for mental health/substance-abuse disorders, (5) educate 50% of the clinical staff on the program, and (6) develop a risk-stratification tool and discharge checklist.

Design

This program was funded, based on milestones by the Centers for Medicaid and Medicare Services (CMS) Delivery System Reform Incentive Payment (DSRIP) 1115 waiver, which aims to boost more-effective care transitions and offers project options to health care systems.10  The program combines 3 technologies as part of the effort to reduce hospital readmissions and ED visits. The technologies are (1) a risk-stratification tool, (2) a telephone call series, and (3) a home visit that includes a telemedicine component. The technologies have been used independently, but never, to our knowledge, been harnessed together. The program's transition-of-care process uses an interdisciplinary approach, including 2 psychiatrists, 5 social workers, 2 case managers, a clinical pharmacist, 2 advanced psychiatric nurse practitioners, 2 educators, and 8 home health care aides. Each team member has an integral role in transitioning the patient from hospital to home. In the context of this transition-of-care program, the clinical pharmacist's responsibility primarily consists of consultations and is dependent on assessments completed by unit nurses, transition-of-care social workers, educators, and transition-of-care nurse practitioners. The Behavioral Health Transition of Care Program uses the Coleman Care Transitions Intervention® (Health Care Policy and Research, University of Colorado, Aurora, CO) as a framework.11  The Coleman model emphasizes four pillars that are the backbone of this program: (1) medication self-management, (2) patient-centered record, (3) follow-up, and (4) red flag identification. The goal is to empower patients in these areas so they can actively participate in their health care.

Setting and Population

Program interventions take place in hospitals, patients' living environments, and community clinics. The program is implemented in 3 of the 7 HMH hospitals: 1 hospital in the Texas Medical Center (HMH Main, 824 beds) and 2 community hospitals serving areas surrounding Houston, Texas (Willowbrook, 241 beds; San Jacinto, 375 beds). The 2013 demographic characteristics of the 3 participating hospitals are as follows: 59% female, primarily white (56%) and black (20%), and primarily 18 to 64 years old (59%). Elderly patients (65 years and older) comprise 40% of the population. Primary payer sources were Medicare (48%) and Medicaid (10%). The program was implemented at HMH Main and Willowbrook in June 2014 and in San Jacinto in September 2014. Participants include adult patients with a primary or secondary diagnosis at high risk for ED visit or hospital readmission. To meet CMS requirements, the program must stratify 2710 patients as high risk for ED visit or hospital readmission by April 2015, using a risk-stratification tool discussed in the next section.

Evidence-Based Tools in the Inpatient Setting

Upon arrival of the patient to the ED or nursing unit, the nurse screens for substance abuse/mental health disorders and uses the RightCare Discharge Decision Support System (D2S2; RightCare Solutions, Horsham, PA) to assess the patient's risk for readmission.12  The D2S2 has been exclusively licensed to RightCare by the University of Pennsylvania. The tool includes questions about symptoms of depression, cognitive status, comorbid conditions, and caregiver availability. The RightCare program calculates a score based on the answers to the tool's questions and other demographic data, such as zip code. Patients scoring 3 or higher (range, 0-11) have a high risk for 30-day readmission and, thus, are enrolled into the Behavioral Health Transition of Care Program. A transition-of-care social worker is consulted to meet with the patient to conduct various assessments using the Medication Discrepancy Tool13  (MDT®), the 8-item Morisky14–16 Medication Adherence Scale (MMAS-8), and the Patient Health Questionnaire-9 (PHQ-9).17  The MDT, developed by Eric Coleman of the Care Transitions Program, provides a facilitation tool to the social worker in identifying transition-related medication problems, including financial barriers and nonadherence.13  The MMAS-8 is a medication-adherence questionnaire validated in elderly outpatients with hypertension and was found to have a sensitivity of 93%, specificity of 53%, and an α reliability of 0.83.14  In the validation study, there was a significant relationship between blood pressure control and MMAS-8 score, thus making it a reliable and practical measure of adherence. Unlike previous uses of the MMAS-8, the questions are asked in a general way and are not specific to a medication class (see the Table for MMAS-8). In this program, if the patient demonstrates low adherence (MMAS-8 score, < 6; range, 0-8), the clinical pharmacist is consulted. The pharmacist uses the information documented in the MDT and PHQ-9 to tailor interventions and coaching.

TABLE:

Morisky medication adherence scalea,b

Morisky medication adherence scalea,b
Morisky medication adherence scalea,b

Inpatient Pharmacist Interventions

Each clinical pharmacist coaching session is patient centered and entails asking open-ended questions to gain an understanding about the patient's nonadherent behavior. Interventions used to improve adherence primarily include psychoeducation and motivational interviewing. In this program, motivational interviewing is used to gain an understanding of the patient's concerns about medications and to determine readiness for change.18  A recently published study19  found that a brief motivational interviewing session on medication adherence was a negative predictor of 30-day readmission. Other interventions may include financial assistance with medications (eg, charity supply of medications or coupons) and modification of the medication regimen (eg, switch to a less-expensive medication or a long-acting injectable antipsychotic). If the patient consents, the clinical pharmacist involves family members or caregivers in coaching. The clinical pharmacist of the transition-of-care program consults with the unit-based clinical pharmacist or prescribing physician if modifications to the medication regimen are needed to improve adherence outside of the hospital. The clinical pharmacist then documents the coaching session in the hospital's electronic medical record system. An intervention documentation system is also used to track and trend clinical pharmacist interventions.

Postdischarge Process

To establish continuity of care and close postdischarge follow-up, the patient gives consent to receive a series of automated phone calls from Emmi Solutions (Chicago, IL) and/or 1 to 2 visits made by a home health care aide.20  Emmi Solutions' interactive Web-based programs and call campaigns deliver actionable health information to patients via multiple modalities at key moments across the continuum of care. Within 1 to 2 days after discharge, the automated phone call asks the patient various questions related to psychiatric symptoms, medications, and follow-up appointments. This close follow-up after discharge is warranted, as recognized by the Texas HHSC report,5  because the second and third days after discharge are the most likely days for potentially preventable readmissions. The educators review daily Emmi Solutions reports and consult with the clinical pharmacist if the patient reports medication-related issues or “red flags” (eg, cannot fill prescription or experiencing side effects). Within 1 to 2 weeks after discharge, the home health care aide visits the patient to reconcile medications and ask a series of questions/scales related to physical and mental health, including the MMAS-8. Each aide carries an iPad (Apple, Cupertino, CA) with a data plan, which enables the aide to instantly upload the results of the medication reconciliation and other assessments to Research Electronic Data Capture (REDCap) tools hosted at the HMH Transition of Care Program.21  The REDCap software is a secure, Web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources. With this innovative technology, the team monitors postdischarge issues while the aide is still in the home with the patient. The nurse practitioner has a telemedicine appointment via iPad to assess the patient and counsel on medical and psychiatric conditions. If necessary, the nurse practitioner refers the patient to one of the program's community clinic partners and consults with the team's psychiatrist for postdischarge issues. The aide also contacts the pharmacist via iPad if he or she needs assistance with medication reconciliation. After the visit, the nurse practitioner refers the patient to the clinical pharmacist to review the medication regimen with the patient or to address financial barriers, including prior authorization issues. The pharmacist or other transition-of-care team members may consult with Care Navigators, an established continuity-of-care program at HMH, for assistance with medication issues in patients with physical conditions, such as cardiovascular disease and chronic obstructive pulmonary disease. By identifying medication discrepancies in the patient's home, a potential hospital readmission may be prevented. After resolving medication-related issues, the pharmacist documents interventions in REDCap. If an enrolled patient returns to the hospital within 30 days after discharge, the transition-of-care team collaborates to identify causes of readmission. Modifications are made to the transition-of-care process as important lessons are learned.

The Behavioral Health Transition of Care Program began in June 2014. Data are currently available from June 2014 to September 2014 and only for HMH Main and Willowbrook sites because the San Jacinto arm began in September 2014. For the 2 hospitals, 770 of the expected 2710 patients have been stratified as high risk since June 2014. The educators and other program members have educated 73.1% of the clinical staff on the program, exceeding the aim of 50%. The readmissions data are pending. Of the 770 patients at high risk for ED visits or hospital readmissions, 382 patients (49.6%) were discharged with a customized care plan and 478 (62.1%) were screened for mental health and/or substance abuse disorders. The risk-stratification tool and discharge checklists were completed before June 2014. Of the 382 patients discharged with a customized care plan, 237 patients (62%) were enrolled in the Emmi Solutions program. Emmi was able to connect to 176 patients (74.3%). There were 95 Red Flag patients and 13% of these patients had medication-related issues. Since June 2014, 65 home visits have been made. Examples of medication-related issues identified postdischarge include no prescriptions, limited transportation to pharmacy, adverse effects, and medication-reconciliation errors. Although readmission data are pending, the program has affected patients in unexpected ways, including referring an actively suicidal patient to a psychiatric hospital and identifying a possible gastrointestinal bleed in a patient on rivaroxaban.

This novel program serves the complex needs of patients with multiple physical and mental comorbidities. As it is a new program, it has various strengths and challenges. The D2S2 and Emmi Solutions tools help to identify specific patient needs and target the team's interventions. The unique professional capabilities of each member on this interdisciplinary team enhance the transition-of-care process. Social workers may help with transportation and insurance issues, the clinical pharmacist reviews medication profiles, and the nurse practitioners assess the patients during the postdischarge visits. Furthermore, the physical proximity of the team members allows for rapid communication, which increases workflow efficiency. Last, this project may change local health care culture for postdischarge patient referral. During calls or home visits, the staff members refer patients with worsening symptoms in need of assessment to community clinics. The community clinics can respond to referrals within 24 hours and provide mental health and primary care services. The program also has several challenges to overcome. Patients often refuse home visits for various reasons. They may already have home health care services or are unclear of the benefits. Certain patients may have symptoms of paranoia and prefer not to have a stranger enter their home. Some patients may consent to the home visits but do not answer the door or telephone before the visit. The program plans to provide additional education and conduct focus groups with high-risk patients to gain an understanding of their perspectives of the program. Achievement of volume of 2710 patients by April 2015 will be challenging but feasible. The patient volume is expected to increase at a faster rate with program implementation in San Jacinto. The educators continue to stress the importance to the nurses of completing the D2S2 risk-stratification tool. Last, communicating therapeutic recommendations is challenging when patients do not have primary care physicians or psychiatrists, despite program efforts to find them one. The nurse practitioners do not have prescriptive authority for their telehealth visits because of restrictions imposed by the state, and hospitalists usually do not modify regimens or prescribe medications post-discharge. As a result, medication changes must be made via outpatient physicians. To address this limitation, the team continues to strengthen ties with the community clinics.

Patients with mental illness and those with physical conditions complicated by psychiatric symptoms tend to have greater difficulty maintaining their health and may benefit from this program. The Behavioral Health Transition of Care Program at HMH offers an opportunity to investigate the value of a uniquely tailored transitional care process in this underserved population. The aim of the program is improve continuity of care for patients with a primary or secondary psychiatric diagnosis. This program is centered on empowering the patient in managing physical and psychiatric conditions and medications. The clinical pharmacist serves to proactively identify and resolve medication-related discrepancies early in the admission and postdischarge phase. With this novel role, the pharmacist collaborates with the rest of the transition-of-care team to bridge the gap and ensure a safe discharge from hospital to home. The patient outcomes data will fill a gap in the literature with essential information on transition-of-care issues within the mental health population. This program has implications to affect health care policy because it uses multiple evidence-based practices with the ultimate goal of decreasing economic burden for health systems and patients. New pharmacist roles in transition-of-care programs may also emerge from this program.

1
Coleman
EA
,
Boult
C
.
Improving the quality of transitional care for persons with complex care needs
.
J Am Geriatr Soc
.
2003
;
51
(
4
):
556
-
7
.
PubMed PMID: 12657079
.
2
Institute of Medicine
.
Crossing the quality chasm: a new health system for the 21st century
.
Washington, DC
:
National Academy Press;
2001
. 8
p
.
3
Burton
R
.
Health policy briefs: improving care transitions
.
Health Aff
[Internet]
.
2012
Sep [cited 2014 Jul 10] [about 6 p.]
. .
4
Kronish
IM
,
Rieckmann
N
,
Halm
EA
,
Shimbo
D
,
Vorchheimer
D
,
Haas
DC
,
Davidson
KW
.
Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes
.
J Gen Intern Med
.
2006
;
21
(
11
):
1178
-
83
. DOI: .
5
Texas Medicaid & Healthcare Partnership
.
Potentially preventable readmissions in the Texas Medicaid population, state fiscal year 2012
.
Austin (TX)
:
Health and Human Services Commission
;
2013
Nov 25
. 58
p
.
6
Coleman
EA
,
Smith
JD
,
Raha
D
,
Min
S-J
.
Posthospital medication discrepancies: prevalence and contributing factors
.
Arch Intern Med
.
2005
;
165
(
16
):
1842
-
7
. DOI: . PubMed PMID: 16157827.
7
Peikes
D
,
Lester
RS
,
Gilman
B
,
Brown
R
.
The effects of transitional care models on re-admissions: a review of the current evidence
.
Generations
.
2013
;
36
(
4
):
44
-
55
.
8
Jackson
CT
,
Trygstad
TK
,
DeWalt
DA
,
DuBard
CA
.
Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions
.
Health Aff
.
2013
;
32
(
8
):
1407
-
15
. DOI: . PubMed PMID: 23918485.
9
Anthony
W
.
Recovery from mental illness: the guiding vision of the mental health service system in the 1990′s
.
Psychiatr Rehabil J
.
1993
;
16
(
4
):
11
-
24
.
10
Texas Health and Human Services Commission [Internet]
.
1115 Waiver: waiver overview and background resources
.
[cited
2014
Jul 10]
. .
11
Coleman
EA
.
The Care Transitions Program® Structure [Internet]
.
Denver (CO)
:
University of Colorado, School of Medicine, Division of Health Care Policy and Research;
2007
[cited 2014 July 10]
. .
12
RightCare
[Internet]
.
Pennsylvania
:
RightCare Solutions, Inc
.;
c2014 [updated 2014; cited
2014
Jul 10]
. .
13
Smith
JD
,
Coleman
EA
,
Min
S-J
.
A new tool for identifying discrepancies in postacute medications for community-dwelling older adults
.
Am J Geriatr Pharmacother
.
2004
;
2
(
2
):
141
-
7
.
PubMed PMID: 15555490
.
14
Morisky
DE
,
Ang
A
,
Krousel-Wood
M
,
Ward
H
.
Predictive validity of a medication adherence measure for hypertension control
.
J Clin Hypertens
.
2008
;
10
(
5
):
348
-
54
.
15
Krousel-Wood
M
,
Islam
T
,
Webber
LS
,
Re
RN
,
Morisky
DE
,
Muntner
P
.
New medication adherence scale versus pharmacy fill rates in seniors with hypertension
.
Am J Manag Care
.
2009
;
15
(
1
):
59
-
66
.
PubMed PMID: 19146365
.
16
Morisky
DE
,
DiMatteo
MR
.
Improving the measurement of self-reported medication nonadherence: final response
.
J Clin Epidemiol
.
2011
;
64
(
3
):
262
-
263
. DOI: .
17
Kroenke
,
K
,
Spitzer
,
RL
,
Williams
,
JBW
.
The PHQ-9: validity of a brief depression severity measure
.
J Gen Intern Med
.
2001
;
16
(
9
):
606
-
13
.
18
Possidente
CJ
,
Bucci
KK
,
McClain
WJ
.
Motivational interviewing: a tool to improve medication adherence?
Am J Health Syst Pharm
.
2005
;
62
(
12
):
1311
-
4
.
19
Hyrkas
K
,
Wiggins
M
.
A comparison of usual care, a patient-centred education intervention and motivational interviewing to improve medication adherence and readmissions of adults in an acute-care setting
.
J Nurs Manag
.
2014
;
22
(
3
):
350
-
61
. DOI: .
20
Emmi Solutions White Papers
[Internet]
.
Emmi Solutions
[cited
2014
July 10]
. .
21
Harris
PA
,
Taylor
R
,
Thielke
R
,
Payne
J
,
Gonzalez
N
,
Conde
JG
.
Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support
.
J Biomed Inform
.
2009
;
42
(
2
):
377
-
81
. DOI: .

Author notes

3

Director, Behavioral Health Transition of Care Program, Houston Methodist Hospital, Houston, Texas

Disclosures: The authors have no disclosures of interest for this work. Program Financial Disclosure: This program is a Funding Opportunity from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. The contents are solely the responsibility of the authors and do not necessarily represent the official views of Health and Human Services or any of its agencies.