Bridging the gap for patients with mental illness

Abstract

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.