Transitional Care Programs to Improve the Post-Discharge Experience of Patients with Multiple Chronic Conditions and Co-Occurring Serious Mental Illness: A Scoping Review

Abstract

The transition from hospital to home can be especially challenging for those with multiple chronic conditions and co-occurring serious mental illness (SMI). This population tends to be Medicaid-insured and disproportionately experiences health-related social needs. The aim of this scoping review was to identify the elements and outcomes of hospital-to-home transitional care programs for people diagnosed with SMI. A scoping review was conducted using Arksey and O’Malley’s methodology. Three databases were searched; ten articles describing eight transitional care programs published from 2013–2024 met eligibility criteria. Five programs focused on patients being discharged from a psychiatric admission. Five of the interventions were delivered in the home. Intervention components included coaching services, medication management, psychiatric providers, and counseling. Program lengths ranged from one month to 90 days post-hospitalization. These programs evaluated quality of life, psychiatric symptoms, medication adherence, readmissions, and emergency department utilization. Notably, few programs appeared to directly address the unmet social needs of participants. While the focus and components of each transitional care program varied, there were overall positive improvements for participants in terms of improved quality of life, increased share decision making, and connections to primary and specialty care providers.

INTRODUCTION

Annually, over fourteen million (one in 20) adults in the United States experience serious mental illness (SMI), including bipolar disorder, major depression, and schizophrenia.¹ Nearly 40% of patients with SMI have four or more chronic conditions, such as diabetes, cardiovascular disease, and chronic pain^2,3 leading to a worse quality of life,⁴ difficulties with self-management,⁵ and higher rates of rehospitalization for medical and psychiatric reasons.^6,7 While known rates of SMI are slightly higher among non-Hispanic White individuals; Black, Hispanic, and Asian patients with mental illness are less likely to access mental health services⁸ and Black patients with SMI experience higher hospitalization rates and lower receipt of medications. Additionally, patients with SMI are more likely to have concurrent substance use disorder, experience homelessness, and be insured by Medicaid.¹ Commonly cited barriers to accessing care for patients with SMI include affordability (54%), not knowing where to go for services (39%), perceptions they can handle it on their own (36%), and not having time to get treatment (21%).¹ Patients diagnosed with SMI experience more frequent rehospitalizations and poorer outcomes following hospitalization,^6,9,10 which could be due in part to poor care transitions.

Given the complexity of managing the care needs of patients with SMI and co-occurring chronic medical conditions, the period of transition from hospital to home can be especially sensitive. Medications may change, hospitalization may exacerbate mental and physical health conditions, and it may be difficult reconnecting to care in the community, especially for mental health support.^9,11 Additionally, patients with SMI have a higher burden of social needs that often go unaddressed.¹⁰ Many hospital-to-home transitional care programs focus on older adults, or on specific medical diagnoses, such as heart failure, and others are beginning to focus more on the social determinants of health. For example, the Transitional Care Model (TCM) focuses on older adults transitioning from hospital to home and has demonstrated reductions in readmissions and costs in randomized trials, but requires additional providers, such as advanced practice nurses.^12,13 Community Health Workers (CHWs) have also helped reduce readmissions for patients with a high burden of social determinants of health, yet they do not immediately address the complex clinical needs of patients.^14–16 The Camden Coalition Core Model, which provides support to “high-cost/high-needs patients,” did not reduce readmissions in its randomized trial for high-cost patients.^17,18 Similarly, the C-TraIn model for economically disadvantaged adults did not reduce 30-day readmissions or emergency department visits.¹⁹ While there are promising aspects of each of these models, none focus specifically on the needs of patients with SMI and co-occurring medical conditions as they transition from hospital to home. We sought to fill this gap with our scoping review to address the following question:

• What are the key elements and outcomes of hospital-to-home transitional care programs for patients with SMI?

MATERIALS AND METHODS

The Arksey & O’Malley five-stage methodology guided our scoping review.²⁰ These stages are (1) identifying a research question, (2) identifying relevant studies, (3) using inclusion and exclusion criteria to select eligible studies, (4) charting the data, and (5) summarizing, collating, and reporting the results.

Stage 1: Identifying the Research Question

Our research team has extensive experience instituting a transitional care program for individuals insured by Medicaid and one team member is also a psychiatric mental health nurse practitioner.^21,22 We sought to fill the following gap in our scoping review of the literature: what are the key elements and outcomes of hospital-to-home transitional care programs for patients with SMI?

Per the Arksey and O’Malley method, we defined what might be ambiguous terms for the reader. For serious mental illness, we were consistent with others in defining this as a diagnosis of major depression, schizophrenia, or bipolar disorder.²³ Because patients with SMI can be hospitalized for psychiatric or non-psychiatric conditions, we included discharges for both types of admissions. Transitional care in the psychiatric literature can mean transitions from a variety of levels of care (e.g., hospital to home or transitional care clinic to other community providers). We were specifically interested in programs where patients with SMI transition from an acute hospital discharge to home.

Stage 2: Identifying Relevant Studies

Our research team consulted the Nursing Librarian at the University of Pennsylvania who assisted with a preliminary search to help identify search terms. Our main search terms included “transitional care”, “hospital to home”, “discharge planning”, “bipolar and related disorders”, “major depressive disorder”, and “schizophrenia spectrum and other psychotic disorders”. We included synonyms for these main search terms as appropriate. Search techniques included Boolean operators, truncation, and phrase searching for each search string. Three databases were searched from January 1, 2013 to October 2, 2024 (PubMed, CINAHL, and PsychINFO). The complete search strategy along with search terms is included in Appendix A.

Our inclusion criteria consisted of 1) patient diagnosis of SMI that was either their primary diagnosis or co-occurring with a medical condition, 2) patient was discharged from an acute care hospital for a psychiatric or non-psychiatric admission, 3) patient was discharged to home, 4) a hospital-to-home transitional care program was described, 5) the article was written in English, 6) the transitional care program occurred in the United States, and 7) the article published within the last 11 years. Exclusion criteria included 1) patients under 18 years of age, and 2) transitions to other settings (e.g., skilled nursing, or rehabilitation center).

Stage 3: Study Selection

Our search of the literature identified 278 articles. Article selection is outlined in the PRISMA diagram (Figure 1). After duplicates were removed, 193 articles remained. Two of our team members (KA and KS) conducted independent reviews of each article by screening the title and abstract to ensure it met our inclusion and exclusion criteria and one team member served as the tiebreaker (JMBC). Then three team members (HB, KA, KS) completed full article reviews to again review whether each article met the inclusion and exclusion criteria. All authors met weekly as a team to discuss questions about each article and to achieve consensus on article selection.

Fig. 1.

PRISMA diagram.

Stage 4: Charting the Data

Included articles underwent data abstraction. Three forms were developed by the team and went through an iterative development process to chart the data and included: 1) article demographics (Table 1), 2) descriptions and outcomes of the transitional care programs (Table 2), and 3) intervention components (Table 3). All data were abstracted by two team members (HB and KS) and discrepancies were resolved through discussion and consensus.

Table 1.

Article demographics

Program	Study	Design	No. of participants	Patient population	Patient demographics
Pharmacist-led intervention	Abraham et al., 201724	Quality improvement (QI) project to evaluate patient and clinician perceptions of a pharmacist-led intervention for injecting long active injectable antipsychotics Study timeframe: 2014–2015	16 healthcare team members and 6 patients interviewed Random selection of 30 patient chart reviews	Diagnosis of serious mental illness (SMI) including schizophrenia and bipolar disorder, who were newly starting on a long-acting injectable antipsychotic after psychiatric hospitalization	83 patients participated in this QI project, but their demographics were not reported as part of this study
Coleman’s Care Transition Intervention (CTI)	Aronow et al., 201825	Secondary analysis of patients who screened positive for depression and participated in a prospective cohort study of the CTI Study timeframe: 2012–2015	937 patients referred to the CTI project who met criteria for depression (out of 4,601 total participants)	Medicare fee-for service-CTI participants screened positive for depression based on PHQ-9 who were being discharged after a non-psychiatric hospitalization	Depressed participants were more likely to be women, under the age of 65, non-English speaking (Korean, Middle Easter/South Asian) and more likely to have Medicaid compared to commercial insurance as their secondary payer
Enhanced Care Transition Intervention (ECTI)	Conner et al., 202126	Pilot randomized controlled trial comparing CTI to ECTI Study timeframe: 2016–2017	21 patients (11 in the ECTI group and 10 in CTI group)	Adults 60 years of age and older from racial and ethnic minority backgrounds who were hospitalized for a medical condition and had co-occurring depression	ECTI participants were 64% female, on average 65 years old, 45% African American, 27% Latino/Hispanic, and 55% were married
Transitional Care Model (T-Care)	Hanrahan et al., 201427	Randomized control trial to evaluate Naylor’s T-Care on posthospital outcomes for individuals hospitalized for an acute psychiatric condition Study timeframe: 3/2011–8/2011	Both studies reported demographics and findings on the same sample: 40 patients (153 screened) randomly assigned to T-Care (n=20) or usual care (n=20)	Adults (ages 18–64) hospitalized for a psychiatric condition and who were diagnosed with SMI and a comorbid health condition, English speaking, and were discharged from a psychiatric unit to home	Mean age was 44 years, 55% male, and 45% African American. Forty percent had less than a high school education, were poor (mean income = $717 per month), and single (60%). At baseline, a quarter lived in emergency shelters, halfway homes or had no place to live
	Solomon et al., 201428	An advisory group of community stakeholders assessed barriers and facilitators of T-Care delivered by a psychiatric nurse practitioner (NP)
Community Care of North Carolina (CCNC)	Jackson et al., 201529	Retrospective cohort analysis to evaluate the effect CCNC’s transitional care program on reducing readmissions for individuals with schizophrenia and a co-occurring chronic medical condition Study timeframe: 7/2010–6/2011	1,104 received transitional care, compared to 613 receiving usual care who were enrolled in a CCNC primary care medical home within 30 days of discharge	North Carolina Medicaid beneficiaries >=18 years of age, with schizophrenia or schizoaffective disorder and a co-occurring chronic medical condition, discharged with a medical or psychiatric reason	43 years old on average, 59% female, 45% African American, 43% admitted for a psychiatric hospitalization
Mobile After-Care Support (MACS)	Moitra et al., 202131	Pilot test to assess feasibility, acceptability, and clinical effects of MACS at baseline and 1-month. Timeframe: not described	10 adult patients	Adults with schizophrenia-spectrum disorders who had a psychiatric hospitalization and are currently on an oral antipsychotic	44 years old on average, 60% female, 30% African American, 87.5% household income < $40,000/year, 20% unemployed
Thrive	Nikpour et al., 2024 30	Sequential explanatory mixed-methods study comparing outcomes of Thrive participants with and without SMI (quant) and exploring the perceptions of satisfaction and acceptability among Thrive participants with SMI (qual). Timeframe: 2/2021–8/2023	252 adult patients received Thrive services (62 with SMI and 190 without SMI)	Adults over the age of 18, who were insured by Medicaid, and were discharged from an acute care hospital for a non-psychiatric stay.	Participants were on average 57 years of age, and 56% were Black. Those with SMI had a higher number of comorbidities compared to those without SMI
Engagement-focused care (EFC)	Velligan et al., 201733	Comparative effectiveness trial randomized participants to usual care or EFC following discharge Timeframe: 8/2014–11/2015	465 adult patients (139 lost to follow-up)	Adults over the age of 18, had SMI, discharged from a psychiatric unit, and were able to give informed consent.	Average age 37, 44% male, and 52% Hispanic
	Velligan et al., 201632	Qualitative study of patients with SMI and caregivers participating in a 90-day outpatient transitional care clinic	10 patients with SMI who participated in the transitional care clinic 8 family caregivers	TCC participants had either schizophrenia spectrum disorders, affective disorders, or anxiety disorders	Half of the patients were male, half were white Hispanic, 2 were African American

Table 2.

Transitional care program descriptions and outcomes

Program	Program description	Hospital and community settings	Studies & Findings
Pharmacist-led intervention	Goal to improve transitional care from acute psychiatric hospitalization to the community for patients taking long acting injectable (LAI) antipsychotics. Medication and counseling provided prior to discharge by a pharmacist. Patients then received outpatient psychiatric treatment and their LAI medications at a nurse-led injection clinic that was scheduled prior to discharge	Hospitalization was in an urban, psychiatric hospital in Southwestern Pennsylvania Outpatient services within walking distance of the psychiatric hospital	Abraham et al., 2017: 4 themes of challenges and facilitators: 1) hesitation by nurses and psychiatrists of the required pharmacist consultation, 2) issues in coordinating the in-hospital LAI administration, 3) lack of communication during the discharge planning process, and 4) ensuring appropriate communication for the outpatient treatment. 5/6 patients reported consistently receiving LAIs in the outpatient setting. Most did not know the name of their medication, nor remembered receiving it in the hospital, and did not remember receiving education. But most preferred the injectable form and thought it was helping.24
Coleman’s Care Transition Intervention (CTI)	A CMS-sponsored demonstration project for Medicare fee-for-service insured individuals who were deemed to be at “high risk” for readmission. Social workers served as CTI coaches for 4 weeks. Initial home visit and 4 weeks (28 days) of follow-up phone call support. Goals: patient and family self-management of medications, follow up with primary and specialty providers, knowing “red flags” of worsening health, and keeping a personal health record (PHR) about these elements and their personal goals	Hospitalizations occurred at 4 large urban hospitals in Los Angeles Home-based follow up after discharge	Aronow et al., 2018: Participants with depression were more engaged with a coach for goal setting, identified medication discrepancies, updated their PHR, encouraged to set follow-up appointments, and to discuss community resources, but less likely to be confirmed that their appointments were scheduled. They were also more frequently offered problem-solving therapy and referral to mental health services, transportation services, meal services, and case management services. They also more frequently had their physician appointments moved to an earlier date by their coach.
Enhanced Care Transition Intervention (ECTI)	An adaptation of Coleman’s CTI, for Medicare-fee-for service insured individuals living with depression who are racially and ethnically diverse CTI plus a trained peer educator who was previously treated successfully for depression. Met weekly with participant for 2 months post-discharge, at least once/month in person. Trained to use motivational interviewing techniques to provide support around their depression management, and to provide emotional and social support. The peer educator met bi-weekly with the study PI to discuss cases and receive feedback and additional training as needed	Hospitalizations occurred at a large, private, not-for hospital in West Central Florida Home-based follow up after discharge	Conner et al., 2021: Quality of life diminished over time for African Americans in the CTI. Those in the ECTI group maintained (African American) or saw an improvement (Latino) in quality-of-life scores. There were no hospital readmissions among the ECTI group and 2 readmissions among the CTI group within 30 days of discharge. Between 30 and 60 days of discharge, 2 ECTI patients and 4 CTI participants experienced a readmission.26
Transitional Care Model (T-Care)	Psychiatric nurse practitioner (NP) conducted a home visit within 24 hours of discharge and then followed participants telephonically for 90 days. They helped participants adapt to home, set goals, often accompanied patients to appointments, and prescribed medications as appropriate.	Hospitalization occurred at 2 psychiatric units within a large acute care hospital Home-based follow up after discharge	Hanrahan et al., 2014: The T-Care group had higher medical and psychiatric hospitalizations, more primary care visits, and improved general health scores compared to usual care. The most frequent reasons for re-hospitalization or ED use included psychiatric symptoms, substance use, unstable housing and conflicts with friends/family.27 Solomon et al., (2014): Patients with SMI who also had a pressing medical need were most receptive to T-Care. Barriers to care for providers had to do with communication and privacy concerns from different health care facilities. The NP was valued by the patients but there was a high level of psychosocial need that there should be consideration for a social worker or peer advisor as an addition to the T-Care team.28
Community Care of North Carolina (CCNC)	An enhanced primary care case management program for Medicaid-insured individuals. Patients are linked to one of 14 primary care medical home regional networks that are nonprofit, physician-led, and participate in care management and QI activities. Behavioral health services offered through nonprofit local providers and overseen by a utilization review company and public local management entities. Each site had a behavioral health coordinator and psychiatrist.	Hospital discharges across 89 of 100 North Carolina. Patients discharged from a psychiatric or medical hospitalization Variety of outpatient services	Jackson et al., 2015: Patient receiving CCNC were 30% less likely to experience a readmission during the year following initial discharge.29
Thrive	An equity-focused transitional care program to address the clinical and health-related social needs of Medicaid-insured and dually eligible Medicare and Medicaid individuals with multiple chronic conditions transitioning from hospital to home. The program includes intensive virtual case coordination, home care services, connections to community-based services, and supervision provided by the discharging physician or an advanced practice provider for 30 days.	Hospital discharges from one acute care urban hospital in the northeast. Home-based follow up after discharge	Nikpour et al., 2024: There were no statistically significant differences in 30-day readmissions, ED visits, primary care, or specialty care visits between Thrive patients with and without SMI. Qualitatively, Thrive participants with SMI were highly satisfied with Thrive services, but wanted stronger connections to behavioral healthcare.
Mobile After-Care Support (MACS)	A smart phone application monitors treatment adherence and symptoms and intervenes with brief just-in-time interventions (5–10 minutes) to support healthy coping skills and treatment adherence using cognitive behavioral therapy for patients with psychosis up to 1-month post-hospitalization.	Hospital discharges from a private, acute-care psychiatric hospital in the northeast region of the U.S Home-based follow up after discharge	Moitra, 2021: Dysfunctional coping strategies and psychiatric symptoms significantly decreased from baseline to 1-month follow up.31
Engagement-focused care (EFC)	Provided during care transition from hospital to home (transitional care clinic) which included a group intake process and share decision making coaching for patients for 90-days. Usual care for all patients includes TCC intake within a week of discharge, medication management, case management, in home services and psychotherapy as recommended by the care team.	Transitional care clinic (the TCC) for post–acute psychiatric patients in Bexar County (San Antonio), Texas Outpatient services	Velligan, (2017): Greater improvement of quality of life for EFC group. Similar levels of treatment engagement between groups. Most patients want a say in treatment decisions.33 Velligan, (2016): This study focused on qualitative experiences with shared decision making and found that patients and caregivers felt a lack of respect from providers including attitudes of prejudice and judgment. Both groups expressed difficulty in accessing mental health treatment services due to lack of insurance or program capacity. Patients felt they were not being listened to during the treatment process and were not given enough time during visits. Both groups were generally positive about psychosocial treatments they did participate in.32

Table 3.

Transitional care program elements

	Med. mgmt. & counseling	In person meetings	Coaching Support	Connection to primary & specialty care	Telephonic support	Family involvement	Assess social needs	Link to long term services	CBT	Virtual Case Management
Home-Based Programs
CTI25	X	X (once)	X (social worker)	X	X	X	X
ECTI26	X	X (monthly)	X (peer educator)	X	X (weekly)	X	X
T-Care27,28	X	X (once)	X (psychiatric NP)	X	X
MACS31	X								X (via mobile app)
Thrive30	X	X (1–3/week)		X			X	X		X (weekly)
Clinic-Based Program
Pharmacist-led24	X	X						X
CCNC29		X		X				X
EFC32,33	X	X	X (shared decision making

Note. CTI = Coleman’s Care Transition Intervention; ECTI = Enhanced Care Transition Intervention; T-Care = Transitional Care Model; NP = nurse practitioner’ CCNC = Community Care of North Carolina; MACS = Mobile After-Care Support; EFC = Engagement-Focused Care; CBT = cognitive behavioral therapy.

Stage 5: Summarizing, Collating, and Reporting the Results

The team described commonalities and differences of transitional care programs in terms of their population focus, program components, and outcomes evaluated. An evaluation of the articles’ quality was not included in this paper as it is not a requirement for scoping reviews.²⁰

RESULTS

Selection of sources of evidence

Forty-one articles were included in the title and abstract screening process and 18 articles underwent full article review (Figure 1). During the full article review process, the research team excluded another five articles due to a lack of focus on hospital-to-home transitional care programs, two articles that were commentaries that did not describe transitional care programs, and one systematic review where most of the included studies were internationally focused and outside the 11-year timeframe. The ten articles in this scoping review describe eight different transitional care programs: 1) a pharmacist-led intervention,²⁴ 2) a secondary analysis of patients with depression who participated in Coleman’s Care Transition Intervention,²⁵ 3) the Enhanced Care Transition Intervention, an adaption of Coleman’s Care Transition Intervention,²⁶ 4) T-Care, an adoption of Naylor’s Transitional Care Model,^27,28 5) a secondary analysis of patients with SMI who participated in Community Care of North Carolina,²⁹ 7) a secondary analysis of patients with SMI who participated in the Thrive clinical pathway,³⁰ 7) Mobile After-Care Support,³¹ and 8) Engagement-Focused Care.^32,33

Study populations

Three of the transitional care programs included patients based on their SMI diagnosis only,^24,31–33 while the other five programs included patients with SMI and co-occurring chronic medical conditions.^25–30 Discharge from a psychiatric unit or hospital was the focus of four programs,^{24,27,28,32,33} three programs focused on hospital discharges for a medical reason,^25,26,30 and one program included discharges for either psychiatric or medical reasons.²⁹ Sample sizes of the programs ranged from 10 to 1,104 participants.^29,31 Participant demographics were not reported in one study.²⁴ Most programs disproportionately included participants from racially, ethnically, or linguistically diverse backgrounds or low-income individuals or who were unemployed or uninsured.^25–33 See Table 1 for additional demographic information.

Transitional care program elements and outcomes

All the programs focused on a hospital-to-home transition but varied in where the majority of the intervention was delivered; five were home-based^{25–28,30,31} and three were delivered in outpatient clinical settings.^24,29,32,33 The transitional care programs also varied in length (one month to 90 days) and intensity of the intervention delivered. For example, the Community Care of North Carolina program was the most “hands off” as an enhanced primary care case management state-wide program²⁹ versus the Enhanced Care Transition Intervention, which provided a peer educator who met weekly with participants for two months following discharge.²⁶ Core elements of the transitional care programs are detailed in Tables 2 and 3.

Synthesis of home-based interventions

Aronow and colleagues conducted a retrospective, secondary analysis of patients with depression who participated in Coleman’s Care Transition Intervention (CTI), a well-established hospital-to-home transitional care program for older adults at “high risk” for readmission following discharge for a medical hospitalization.²⁵ The CTI employs a social worker who helps coach the participant over four weeks, first in person and then over the phone. They assist in goal setting, self-management, understanding medications, following up with appropriate outpatient providers, and providing education on “red flags” of worsening health. The coach also assesses social needs and connects participants with community-based services such as meal delivery and transportation. Aronow and colleagues found that CTI participants who screened positive for depression were more likely to engage with a coach for goal setting, medication management, and to discuss community resources compared to CTI participants without depression.²⁵ CTI participants with depression were also more frequently offered problem-solving therapy and referral to mental health services, transportation services, meal services, and case management services. They also more frequently had their physician appointments moved to an earlier date by their coach.²⁵

The Enhanced CTI (ECTI), built on these initial findings and adapted the CTI for older adults with depression who were discharged from the hospital for a medical reason with the added element of a trained peer educator who previously had depression. The peer educator, instead of the social worker, served as the coach and met with participants weekly for two months following discharge with at least one of those visits each month being in person. The ECTI participants also received the same services as CTI participants described above. Compared to the usual CTI, participants in ECTI either maintained or improved quality of life scores. Within the first 30 days of discharge, no participants in ECTI were readmitted, and only two participants were readmitted within 30 and 60 days of discharge.²⁶

Hanrahan et al., and Solomon et al. both present findings from the Transitional Care Model (T-Care), an adaptation of Naylor’s well-established Transitional Care Model.^27,28 Like the CTI and ECTI, T-Care includes home visits and phone follow-up but continues for 90 days post-psychiatric hospital discharge for patients with SMI and co-occurring medical conditions.^30,31 T-Care involves a psychiatric nurse practitioner (NP) who provides the home and phone follow-up. Like the peer educators within CTI and ECTI, the psychiatric NP assists with goal setting and accompanies the patient to appointments. The psychiatric NP is also able to prescribe and adjust medications as appropriate. Hanrahan et al. found that the T-Care group, compared to usual care, had higher medical and psychiatric hospitalizations, but also more primary care visits and improved general health scores.²⁷ The most frequent reasons for rehospitalization and ED visits included psychiatric symptoms along with unaddressed social determinants of health, such as unstable housing.²⁷ Solomon et al. found that barriers to the program included the high level of psychosocial needs that were not being addressed, and providers involved in the program thought the addition of a social worker or peer advisor to the T-Care team could further enhance patient experiences.²⁸

Nikpour et al., conducted a sequential explanatory mixed-methods study of participants with SMI who participated in the Thrive clinical pathway, a 30-day interdisciplinary case management program that is equity-centered and focused on addressing unmet health-related social needs and clinical needs.³⁰ Thrive was originally designed for patients with multiple chronic conditions insured by Medicaid or who were dually eligible for Medicare and Medicaid who were hospitalization for a medical condition. Thrive participants receive home care services including skilled nursing and a social worker who facilitates connections to community-based resources. The discharging physician or advanced practice provider provides extended supervision for up to 30 days or until participants have been seen by their primary care provider. Each participant is discussed at weekly virtual interdisciplinary case conferences for 30 days following hospitalization. These meetings focus on assessing and addressing the social determinants of health such as housing, food insecurity, and substance use services as needed. There were no statistically significant differences in post-discharge readmissions or emergency department visits for Thrive participants with and without SMI. In qualitative interviews of Thrive participants with SMI, patients noted that while they were satisfied with care coordination and felt their health-related social needs were met, there was a lack of focus on their behavioral health needs.³⁰

Finally, the only technology-focused intervention was Moitra and colleagues’ Mobile After-Care Support (MACS) smartphone application that monitored treatment adherence and symptoms for adults with schizophrenia, discharged from a psychiatric admission and were currently taking an oral antipsychotic medication.³¹ The application prompts participants to track psychiatric symptoms and provides brief “just-in-time” cognitive behavioral therapy interventions to assist with healthy coping strategies. In a feasibility study of MACS, there was a statistically significant decrease in dysfunctional coping strategies and psychiatric symptoms from baseline to one-month follow-up among participants using the application.³¹

Synthesis of clinic-based interventions

Abraham and colleagues developed a pharmacist-led intervention to improve adherence to long-active injectable antipsychotics following an acute psychiatric hospitalization.²⁴ The intervention offered counseling and medication administration before discharge by a pharmacist. Follow-up medication administration appointments were scheduled at a nurse-led injection clinic. Most patients kept their follow-up appointments but did not retain much of the medication counseling they received before hospital discharge, though they felt the long acting version of their medication was generally helpful to them.²⁴

Community Care of North Carolina (CCNC) was a population-based transitional care program for Medicaid-insured individuals that provided enhanced primary care case management by connecting participants to primary care medical homes following a medical or psychiatric hospitalization. Like the CTI, it was not designed specifically to meet the needs of patients with co-occurring SMI diagnoses. Jackson and colleagues conducted a secondary retrospective analysis to determine how effective CCNC was for individuals with co-occurring schizophrenia and another medical condition (e.g., diabetes, hypertension, congestive heart failure).²⁹ In addition to connecting patients with a primary care medical home, CCNC would connect patients to behavioral health services as needed. At each participating site, there was a behavioral health coordinator and psychiatrist. While it is unclear what specifically CCNC participants with co-occurring schizophrenia received, they were 30% less likely to experience readmission the year following the initial discharge compared to usual care.²⁹

Finally, Velligan et al. in 2016 and 2017 described an enhancement to an established Transitional Care Clinic (TCC) called Engagement Focused Care (EFC) that provided linkage to outpatient mental health care up to 90 days following psychiatric hospitalization.^32,33 The hallmark of the EFC enhancement is shared decision-making with a coach. The goal of shared decision-making was to enable the patient to feel they have a more active role in their treatment plan, including medication and participation in psychotherapy. The coach would meet with clinic patients before or after appointments with providers. Visits would last 15 minutes to an hour. Participation in the EFC group demonstrated greater improvement in quality-of-life scores and patients generally liked participating in shared decision-making.^32,33

DISCUSSION

This scoping review aimed to describe the components and outcomes of hospital-to-home transitional care programs for patients with an SMI diagnosis. Over the course of 11 publication years, we found ten articles describing eight hospital-to-home transitional programs for patients with SMI that varied in terms of setting, populations served, program elements, and duration. Together these studies highlight the multiple needs and challenges faced by patients with SMI when they transition from hospital to home. They highlight the importance of including mental health professionals in the delivery of these interventions as well as the importance of shared decision-making, and the intensity of services needed.

The majority of the transitional care programs included in this scoping review disproportionately cared for participants who were unemployed or low income, or from racially, ethnically, or linguistically diverse backgrounds,^25–33 who are most at risk for poor mental health outcomes,⁸ and are more likely to have a higher burden of unaddressed health-related social needs. Tailoring transitional care programs to meet their unique needs is essential. This is especially noted by Hanrahan et al.’s evaluation of T-Care that found that one of the most frequent reasons for re-hospitalization was related to unmet health-related social needs.²⁷ An additional qualitative study of an advisory group for T-Care noted that participants may benefit from other support such as a social worker or peer advisor.²⁸

Components of SMI transitional care programs

The components of these eight programs varied widely but medication management, counseling, and the involvement of a coach, either a health professional or peer, were the most commonly included components. Peer support, as used by the Enhanced Care Transition Intervention,²⁶ which included racially and ethnically diverse patients with depression, may be particularly important to helping to reduce disparities in mental health outcomes and is supported by other literature. For example, in a systematic review of 39 trials on community health worker (CHW) programs globally, the involvement of CHWs demonstrated improved mental health outcomes.³⁴ Similarly the Veteran’s Health Administration has a peer support program, PARTNER-MH, that engages racial and ethnic minority veterans in mental health care. This program has resulted in higher retention rates and improved mental health symptoms.³⁵ This peer support was especially beneficial when it was racially and ethnically concordant.^36,37

Medication management and connection to psychiatric and counseling services are cornerstones of high-quality mental health care for patients with SMI. Given that about 35% of patients with SMI do not receive treatment,³⁸ transitional care programs can help make these critical connections. The pharmacist-led intervention described by Abraham and colleagues focuses on education while inpatient and connection to a community clinic to continue injections for long-acting injectable antipsychotics. Results from the intervention provided pilot evidence that most patients consistently went on to receive their medication injections but did not focus on connections to counseling and other mental health services.²⁴ Providing coaching and peer support, as several of the models describe, was another successful modality to help with goal setting and medication management.^{25–28,32,33} This is another important component for patients with SMI and those who also have co-occurring chronic conditions to enable patients to manage competing physical and mental health priorities.

Support for adapting transitional care programs for patients with SMI

In recognition of the unique needs of patients with SMI who transition from hospital to home, whether for a psychiatric or non-psychiatric reason, two of the identified programs, the Enhanced Care Transition Intervention (ECTI) and T-Care, were adaptations of well-established transitional care programs, Coleman’s Transition Intervention (CTI) ³⁹ and Naylor’s Transitional Care Model (TCM),¹³ respectively. Both programs originally focused on older adults transitioning from hospital to home and were then adapted specifically for patients with depression (ECTI) and SMI (T-Care). The CTI was adapted to the ECTI by exchanging a social worker health coach with a peer educator who was previously successfully treated for depression. T-Care adapted the TCM by employing a nurse practitioner who holds a specialty certification in psychiatric-mental health. Tailoring these traditional transitional care models to more specific patient populations allowed them to better meet the unique needs of patients diagnosed with mental illness. However, neither had an explicit focus on the social determinants of health, which was noted as a potential reason for higher readmission rates among patients participating in T-Care.²⁷

Programs for psychiatric versus non-psychiatric hospitalizations

While all of these transitional care program evaluations included patients with mental health diagnoses, four included participants admitted for a psychiatric reason (Pharmacist-led intervention, T-Care, MACS, and ECF),^{24,27,28,32,33} three for a medical reason (CTI, ECTI, and Thrive)^25,26,30, and one (CCNC) for either reason.²⁹ All of the programs, regardless of hospitalization type, included medication management and counseling as one of their components and most offered some kind of coaching. Programs that were specifically for discharges from a psychiatric unit also included an element of psychosocial support either in the form of cognitive behavioral health or coaching. In contrast, programs that focused on discharges from non-psychiatric units more frequently included components focused on connections to primary and specialty care providers and assessing health-related social needs.

Overall, these programs reported on a variety of outcomes including medication adherence (pharmacist-led intervention),²⁴ engagement with health coaches (CTI),²⁵ quality of life and general health (ECTI, T-Care, EFC),^26,27,33 connecting participants to primary care, specialty care and community-based resources (CTI, T-Care, Thrive),^25,27,30 and coping skills (MASC).³¹Other program evaluated post-discharge utilization including readmissions (ECTI, T-Care, CCNC, and Thrive)^26,27,29 and emergency department utilization (Thrive).³⁰ While promising, these outcomes should be interpreted with caution due to variations in methodological approaches ranging from secondary observational descriptive designs and randomized control trials, as well as their heterogeneous populations and program components.

Limitations

One limitation of this scoping review was the variability in the elements of each transitional care program. We were not able to ascertain whether there was a particular element that was of more importance compared to another. Additionally, several of the studies had smaller sample sizes and most were limited to a single setting or small geographic area, which can limit generalizability.

Conclusions

This scoping review identified eight programs to support patients with SMI as they transition from hospital to home. While none of the programs included a consistent element, these programs included coaching services, medication management, psychiatric providers, and counseling. Several programs noted an increase in quality of life, a decrease in psychiatric symptoms, and an increase in medication adherence; findings on readmission were mixed. Together, they provide evidence of the importance of including a plan to support behavioral health needs for patients transitioning from hospital to home with co-occurring SMI regardless of their reason for hospitalization.

Highlights.

• Transitions are challenging for patients with SMI and chronic medical conditions.

• Few programs address their unique needs.

• Those that do focus on coaching, medication management, and counseling.

• Programs improved quality of life, medication adherence, but had mixed on readmission results.

• Program varied, but few addressed health-related social needs.