Care Transitions for Older Adults With Serious Mental Illness: Triple Jeopardy for the Triple Aim

In 2008, the Institute for Healthcare Improvement (IHI) proposed the “Triple Aim,” that is, that the US health system simultaneously pursues the following aims: 1) to improve the experience of care (including quality, access, and reliability); 2) improve the health of populations; and 3) reduce per capita costs of health.¹ One major focus for achieving the Triple Aim in our highly complex system is improving care transitions. Indeed, one study on Medicare patients suggested that 13.3% of 30-day hospital readmissions were potentially preventable at an additional health care cost of 12 billion dollars.² A major focus of the Affordable Care Act (ACA) has been to incentivize coordination of care across transitions as a strategy to reduce healthcare spending and improve healthcare and patient experience.³ A recently published report based on Medicare and Medicaid data shows that patients with serious mental illness (SMI) are nearly 2 times as likely to have an unplanned 30-day readmission after discharge compared to control patients without SMI,⁴ suggesting patients with SMI may be at higher risk for transitional care. In this issue, Conlon et al. expand the consideration of care transitions to include intrahospital care transitions and present preliminary findings from a quality improvement study showing that older adults with SMI are more likely to undergo these kinds of care transitions when compared to a nongeriatric cohort.⁵

The Conlon report supports the notion that the obstacles to effective care transitions inherent to the current US healthcare system are additionally challenging for older adults with SMI navigating this landscape. This poses a Triple Jeopardy for the Triple Aim:

First, our overall health system is siloed and fragmented.

This systemic fragmentation is particularly present with regard to behavioral health care, which has been historically separated in structure, practice, training, resources, payment arrangements and policy.^12–14 Further, individuals with behavioral health conditions often face stigma that adds additional complexity in navigating our “non-system” of care, irrespective of undergoing a transition in care.

Second, the transition process itself poses difficulties for all patients and those with SMI face special challenges navigating the healthcare transitions.

Recent studies show that patients with SMI are more likely to have transitions in care,⁴ putting this population at increased risk for miscommunication, duplication of services, medical errors, provision of care in conflict with the individual’s and family’s goals,⁶ and rehospitalization within 30 days. Indeed, 4 out of the top 10 conditions associated with 30-day readmissions among Medicaid beneficiaries were behavioral health conditions, totaling over 4/5 of a billion dollars. Moreover, there is evidence that care transitions pose significant risk,⁷ and interventions to improve transitions in care reduce mortality.⁸ There is evidence that within the medical setting older adults and adults with SMI experience many transitions of care,^9–11 and the Conlon et al. study suggests that transitions among and within hospital-based psychiatric and medical settings also disproportionately affect this population.

Third, older age adds its own unique set of circumstances with associated additional vulnerabilities.¹⁵

This includes not only the increasing burden of medical illness with age and comorbidities but also social determinants of health.¹⁶ These vulnerabilities span all domains of function, and pose several systematic, psychosocial, functional, and financial barriers to successful transitions of care.¹⁷

Conlon et al. conclude with a vignette of an older patient with SMI and medical comorbidity navigating through multiple transitions of care. They then present a number of possible interventions that could have improved this patient’s experience and outcome including: having a dedicated caregiver for transitions, patient empowerment, early involvement of family and caregivers, patient care interventions, telecare and sensor-based monitoring, collaboration with the hospital pharmacist, timely exchange of documentation, and the integration of mental health and other medical specialties. These interventions are presented as specific to the vignette but incorporate ideas that have a strong evidence base in transitional care literature.

In 2015, the National Association of State Mental Health Program Directors (NASMHPD) released a report examining what strategies might reduce psychiatric rehospitalizations in patients with SMI.¹⁸ The Triple Aim was already 7 years old and a number of care transition models were already either published or in development in other fields of medicine. The NASMHPD report details over 8 of these models and identifies recurring concepts, including a number of those cited by Conlon et al. However, the NASMHPD report goes a step further to comment on policy level initiatives that could facilitate change. For example, the Affordable Care Act (ACA) established public reporting systems of quality and outcome metrics. The NASMHPD report (and by Viggiano et al.¹⁹) discuss the development of care pathways with quality metrics and feedback as a way to systematically propose standard improvements to transitional care problems and rigorously test whether these solutions produce changes in meaningful outcomes. Also, while Conlon et al. bring up the problem of siloed care, the NASMHPD details the importance of transition planning and shared accountability; both of which suggest policy-level changes that could improve care. In 2016, Chung et al. proposed a framework to integrate behavioral health and primary care as one way to address the current fragmentation of US healthcare that included elements of shared accountability and engagement of multiple providers in mutual care planning.²⁰ This continuum framework could additionally be adapted for intrahospital transitions. Similarly, frameworks are being developed to improve health service delivery to older adults that can be further augmented with a focus on transitional care for this population. An example of this is the age-friendly health system, which proposes the 4Ms: what matters, medication, mentation, and mobility.²¹ A recent article also highlights how family involvement can be an important factor in improving care transitions.²²

The Conlon et al. paper is an initial step to better understanding issues of transition care in older patients with SMI and highlights the vulnerability of this population to what we term Triple Jeopardy to the Triple Aim. Further, it is one of the first studies to focus on intrahospital transitions of care, expanding the scope of transitions beyond the shift between inpatient and outpatient settings. The Conlon et al. paper highlights the vulnerability of older patients with SMI to intrahospital transitional care and also, importantly, demonstrates the importance of considering intrahospital movement (and consequences) when considering and implementing models to help improve outcomes. In the future, more studies will have to examine the role of intrahospital movement in outcomes and determine whether interventions that have proven effective in transitional care apply to this particular sort of event. Developing specific practices and policies which are rooted in evidence-based trials are needed to improve care for those patients at risk for triple jeopardy.