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. 2019 Nov 25;19:883. doi: 10.1186/s12913-019-4658-0

Table 1.

Tabulation and description of the studies used in the systematic review

ID Authors and year Location and setting Intervention Participants Method Main findings Main aim/ problem to address
1 Abraham et al. (2017) USA, 1 urban psychiatric hospital Pharmacist involvement to improve care co-ordination 16 health professionals, 6 patients, 20 patient charts (SMI patients) Evaluation- interviews and observations of charts

Increased pharmacist involvement in LAI care coordination may contribute to bridging gaps in medication adherence to optimize

treatment outcomes.

To support long-term medication adherence and patient outcomes
2 Attfield et al. (2017) UK, 2 trusts Diagnostic-driven Integrated Care Pathways (ICPS) A random sample of 400 service users Retrospective case comparison study The ICP Trust had a 13.5 day shorter average length of stay, (statistically significant). No significant differences in readmission or 7-day follow-up. Reducing unnecessary tests, interventions and duplication within the care process
3 Bauer et al. (2012) Germany, 1 hospital

SMS-based

maintenance intervention

165 females. Eating disorders RCT Somewhat significant difference in readmission (depending on analysis). Significant difference in treatment utilisation. Maintain treatment
4 Bennewith et al. (2014) UK, 3 inpatient wards in southwest England, mixed urban/rural A contact-based intervention for people recently discharged (letters sent to sus) 102 patients received a letter, 45 received all letters Pilot case study. Interviews, analysis of outcomes (readmission) Post-discharge, qualitative interviews with service users showed that most already felt adequately supported and the intervention added little to this. To reduce suicide post-discharge by providing social connectedness
5 Bonsack et al. (2016) Switzerland, 1 psychiatric hospital Transitional case management 51 intervention, 51 control RCT

Increased short-term rate of engagement with ambulatory care despite no differences

between the two groups after 3 months of follow-up. Intervention did not significantly reduce the rate of readmissions during the first year following discharge.

Improve engagement with care, reduce readmission
6 Botha et al. (2018) South Africa, 1 hospital 90-day transitional care intervention (four phone calls and one home visit, focusing on maintaining adherence, appointment reminders and psychoeducation.) 60 male patients Retrospective comparison to matched control group No effect on readmission rates in this setting. Bridge gap, reduce readmissions
7 Chen (2014) USA, all of the community agencies providing CTI in NYC (4)

Community support in critical time intervention (CTI)a time-limited, short-term psychosocial rehabilitation.

Program designed to facilitate the critical transition from

institutional to community settings

12 CTI workers Interviews CTI workers self-identified as “extra support” to develop community ties that will help clients sustain stable housing. Propose a transient triangular relationship model, involving three dyadic relationships (worker-client, worker-primary support, primary support client). To facilitate effective transitional services and enhance continuity of care. Breaking the vicious cycle between institutionalization and homelessness
8 D’Souza (2002) Australia, rural hospital Telemedicine (psycho-educational programme and MDT videoconferencing post-discharge) 51 (24 intervention, 27 control) male and female Controlled study More side effects in control group, more treatment adherence and satisfaction in intervention group. Improve treatment adherence
9 De Leo and Heller (2007) Australia, 1 psychiatric inpatient unit Intensive case management follow up of high risk people (ICM was weekly face-to-face contact with community case manager and telephone calls from counsellors) 60 male service users with a history of suicide attempts RCT (TAU or intervention) People in ICM had lower depression scores, suicidal ideation, QoL, more contact with services, better relationships with therapists and were satisfied with service. A solution to the reduced care following discharge that is linked to suicide.
10 Exbrayat et al. (2017) France, single centre

Telephone

follow-up 8,30 and 60 days post attempted suicide

436 patients (387 control patients who were matched from pre-intervention records) Controlled study Very early telephone follow-up of our patients effectively reduced recidivism and seemed to be the only protective factor against repeated suicide attempt. To reduce suicide attempts post-discharge
11 Forchuk et al. (2005) Canada, 26 wards, 4 hospitals Transitional discharge model (TDM) 390 Randomised clinical trial using a cluster design Costs and quality of life were not significantly improved post-discharge compared with the control group. Although not predicted a priori, intervention subjects were discharged an average of 116 days earlier per person. Reduce bed occupancy, improve quality of life
12 Forchuk et al. (2008) Canada, 1 hospital Intervention to prevent homelessness- immediate assistance in accessing housing and assistance in paying their first and last month’s rent 14 participants at risk of being discharged without housing (7 in intervention group) RCT, incl. interviews All intervention group maintained housing after 3 and 6 months. All but one individual in the control group remained homeless after 3 and 6 months. Results of this pilot were so dramatic that randomizing to the control group was discontinued To reduce discharge from inpatient wards to shelters or the street
13 Forchuk et al. (2012) Canada, 6 hospitals Transitional relationship model (TRM) (providing hospital staff involvement until a therapeutic relationship has been established with a community care provider as well as peer support.) No participant numbers as ethnographic analysis. 14 A wards, 12 B wards and 10 C wards.

A quasi-experimental, action-oriented

research design

Staged large-scale implementation allowed for iterative improvements to the

model leading to positive outcomes. This study highlights the need to address work environment issues, particularly inter-professional teams.

To improve staff uptake of interventions
14 Forchuk et al. (2013) Canada, all patients in Ontario at risk of homelessness, 1 acute care hospital, 1 territory

Intervention to prevent homelessness -

Pre-discharge assistance in securing housing

112 men and 107 women at risk of homelessness post-discharge Programme evaluation design- interviews, focus groups The results highlight several benefits of the intervention and show that homelessness can be reduced by connecting housing support, income support, and psychiatric care. To stop people being discharged to street or shelters
15 Ghadiri Vasfi et al. (2015) Iran, 1 hospital

Aftercare Services (three components: follow-up

Care (home visits or telephone follow-up), family psychoeducation, And social skills training for patients.)

120 patients (schizophrenia and bipolar) ages 15–65. 60 control RCT The cumulative number of hospitalizations during the follow-up period was 55 for the control group and 26 for the intervention group. Length of stay was significantly greater in the control group. Psychopathology was significantly less severe in intervention group compared with the control Reducing readmissions and length of stay
16 Hampson et al. (2000) UK, 1 trust (North Nottingham and Hucknall) Community Link Team (CLT) to facilitate early discharge- team-based service offering intensive support during the day 142 (all admissions to team in 12 month period) Retrospective comparison Median length of stay during CLT project was 19 days, a highly significant reduction from 36 days in the NABUS study. Cannot be attributed to team but justifies a RCT to test this hypothesis, To speed up discharge due to costs to provider and patients
17 Hanrahan et al. (2014) USA, 1 hospital Transitional care model (TCM) 40 (20 control) RCT The intervention group showed higher medical and psychiatric rehospitalisation than the control group. Emergency room use lower for intervention group but not statistically significant. Continuity of care with primary care appointments were significantly higher for the intervention group. The intervention group’s general health improved but was not significant Reduce transition failures
18 Hegedus et al. (2018) Switzerland, 2 wards, 1 hospital Short transitional intervention in psychiatry (step) 14 control, 15 intervention Quasi-experimental pilot study to determine the feasibility of the intervention, The intervention did not affect primary or secondary outcomes; however, it was shown to be feasible, and patients’ feedback highlighted the importance of post-discharge contact sessions. Prepare patients for situation outside of hospital
19 Hengartner et al. (2015) Switzerland, 1 catchment area, which is an urban/suburban area of high-level resources near the city of Zurich Post-discharge network coordination 3 patients Case studies- narrative review and qualitative analysis of three patients who participated in the program

Case reports revealed that patients’ social networks are small and their

relationships are commonly conflictual and unstable.

Reducing readmission, improving mental health and psychosocial functioning. Improve hospital discharge planning and to ease the transition
20 Hengartner et al. (2016) Switzerland, 1 catchment area, which is an urban/suburban area of high-level resources near the city of Zurich Post-discharge network coordination 151 patients RCT using parallel group blocking In the short-term, no significant effect emerged in any outcome. In the long term the two groups did not differ significantly with rate and duration of rehospitalisation. The intervention did not reduce psychiatric symptoms, did not improve social support, and did not improve quality of life. Reducing readmission, improving mental health and psychosocial functioning. Improve hospital discharge planning and to ease the transition
21 Herman et al. (2011) USA, 2 transitional residences in hospital grounds metropolitan area Critical Time Intervention to prevent homelessness 150 previously homeless men and women with SMI RCT CTI group had less homelessness than TAU Reduce homelessness following discharge
22 Jenson et al. (2010) Canada, poor city, high unemployment, 1 acute ward and 1 community service provider within same region Community-Based Discharge Planning (in-reach model- discharge planner based in community visits ward daily) 36 service users Single group programme evaluation, analysis of admin data and interview with clients

Readmission rates were 40% lower in the year following

the change in service delivery model. This change was statistically significant.

To shift mental health services from institution to community
23 Juven-Wetzler et al. (2012) Israel, 1 ward “Continuation of Care” model (continuing follow-up in the ward, by the same staff, instead of being referred to the outpatient department.) 35 service users Pre and post within participant design

The number of hospitalizations in the 18 months following the index hospitalization was 1.79 _ 3.51 as compared to 4.67 _ 1.79 before the index hospitalization (p = 0.0002), and the number of days of hospitalization

18 months after was 24 _ 41.65 as compared to 119.71.

To reduce length of stay and readmission
24 Kariel-Lauer (2000) Israel, 1 hospital Re-entry group (short-term group meetings- psychoeducational approach) 75 participants (42 in intervention) men and women A controlled study Intervention group had less readmissions, high rates of absorption into therapy and remaining in therapy Reduce hospitalisations, increase compliance with outpatient appointments
25 Kaspow and Rosenheck (2007) USA, 8 veteran medical centres

Critical time intervention

Case management (a modification of the critical time intervention

(CTI) community case management model)

278 control cohort, 206 intervention cohort Nonrandomized pre–post cohort design

19% more days housed in each 90-day reporting period over the one-year follow-up and 14% fewer days in institutional settings. Veterans

In phase 2 also had 19% lower addiction severity index alcohol use scores,14% lower drug use scores

And 8% lower psychiatric problem scores

Reduce homelessness,
26 Khaleghparast et al. (2013) Iran, 2 hospitals Discharge planning (self-care training programme/nursing process model) 46 service users Longitudinal clinical trial

The intervention group had improved clinical symptoms and higher knowledge levels compared with control group.

Statistically significantly lower readmissions in the intervention group.

To increase patient knowledge, reduce clinical symptoms and rehospitalisation.
27 Khanbhai et al. (2018) Australia, 1 medical centre Discharge checklist 230 checklists Quasi-experimental, pre–post intervention design There was a small, but statistically non-significant, reduction in readmission rates. Reduce readmission
28 Kidd et al. (2016) Canada, 1 large hospital in city ‘Welcome Basket.’ (6 week peer support, contact on wards, basket of items, environmental support) 23 Evaluation- a mixed methods design, pre-post for quantitative outcomes, interviews and readmission rates Pre–post analysis indicated no change in psychiatric symptoms but improvement in community functioning, community integration, and quality of life. No difference in readmission Reduce suboptimal outcomes in first month, bridge gap
29 Kisely et al. (2017) Australia, 1 hospital- intervention and control wards within it Motivational aftercare planning (motivational interviewing with advance directives) 100 intervention plans, 197 control, 20 service user interviews Controlled before-and-after design, interviews Intervention ward improved significantly (e.g. identification of triggers significantly increased from 52 to 94%, This did not occur in the control wards. Interviews showed improvements in experiences of discharge planning. To increase patient input into discharge planning, increase treatment plan following
30 Lawn et al. (2008) Australia, 3 hospitals Peer support No participant numbers in evaluation Evaluation methodology. Intervention at this stage of their recovery seems highly effective as an adjunct to mainstream mental health services. It has personal benefit to consumers and peers, substantial savings to systems, as well as much potential for encouraging mental health service culture and practice towards a greater recovery focus and improved collaboration with GPs To reduce hospital avoidance and facilitate early discharge
31 Lin et al. (2018) Taiwan, 1 hospital Needs-oriented hospital discharge planning for caregivers 114 caregivers (of people with schizophrenia) 57 in each group A quasi-experimental research design The caregiver burden and health status of the experimental group improved more significantly compared with control group. Reducing readmission and improving medication adherence, reducing care giver burden
32 Puschner et al. (2011) Germany, 5 hospitals Needs-oriented discharge planning intervention 491 Multicentre RCT No effect of the intervention on outcomes. Reduce high utilisation of inpatient care
33 Reynolds et al. (2004) Scotland, 1 unit, 3 wards Transitional Discharge Model (ward nurse worked with SU until relationship built with community nurse, then support from service users) 25 services user (14 control, 11 experimental) Randomised experimental design Both control and experimental group demonstrated significant improvements in symptom severity and functional ability after 5 months. Usual treatment subjects in the control group were more than twice as likely to be re-admitted to hospital. Readmissions and not able to adapt to community, focus on need for relationships
34 Rose et al. (2007) USA, 1 large urban medical centre, mostly African- American patients Transitional care model a nurse-based in-home transitional care intervention 10 service users (schizophrenia, bipolar) Evaluation- analysis of nurse logs Offers an alternative to patients who might otherwise be left poorly treated or untreated in the community setting. Lack of continuity of care and meet immediate post discharge needs of SU
35 Sato et al. (2012) Japan, 5 hospitals

Community re-entry program. Discharge preparation program (psychosocial program for preparing long-term

hospitalized patients)

26 intervention, 23 control (schizophrenia) RCT

The program may be capable of promoting discharge of long-term hospitalized psychiatric patients.

There was no significant difference between both groups for number of patients discharged 6 months after end of program.

To reduce length of stay
36 Scanlan et al. (2017) Australia, 3 geographical areas, large non-governmental mental health service Peer-delivered, transitional and post-discharge support program 38 service users Evaluation, outcome measures, interviews Participants reported improvements in functional and clinical recovery and in the areas of intellectual, social and psychological wellness. Self-report of hospital readmissions suggested that there was a reduction in hospital bed days following the program Reduce readmission, increase wellbeing
37 Shaffer et al. (2015) USA, 6 community-based provider organizations within network of a not-for-profit, managed behavioural health care organization Brief critical time intervention (a brief, three-month version of CTI) 149 adults with readmission within 30 days, 224 control A quasi-experimental investigation BCTI was associated with decreased early readmission rates, Reduce readmission
38 Shaw et al. (2000) Scotland, 3 acute wards, 1 hospital Pharmacy discharge planning (receiving a baseline Pharmaceutical needs assessment, information about medicines and then a Pharmacy discharge plan sent to their community pharmacy) 97 service users Controlled study

No significant difference between the groups in baseline medicine knowledge. One week post-discharge, both groups showed

Significant improvement in knowledge of medication from baseline and was maintained at 12 weeks.

Fewer medication problems for the intervention group.

To reduce medicine-related problems that cause readmission
39 Simpson et al. (2014) UK, 4 wards, inner city (London) Peer support 46 service users 23 peer support 23 control Pilot randomised controlled trial with economic evaluation No statistically significant benefits for peer support for hope or QoL, there is an indication that hope may be further increased in those in receipt of peer support. The total cost per case for the peer support was £2154 compared to £1922 for control. To increase hope and quality of life
40 Smelson et al. (2010) USA, 1 acute inpatient psychiatric unit Brief Treatment Engagement (5 h per week of services- assertive community treatment using BCTI, peer support, dual recovery therapy) 102 veterans, (56 control) Prospective randomized trial

69%

Of intervention participants attended an outpatient appointment within 14 days of discharge, compared to only 33% of control. Intervention participants were also significantly more likely to be engaged in outpatient services at the end of the intervention period.

Treatment engagement
41 Taylor et al. (2014) USA, 1 large psychiatric hospital

Brief care management

Intervention (brief interview prior to discharge)

87 intervention, 108 control, 195 total Controlled study Individuals in the control group were more likely to be readmitted within 30 days of an index readmission than individuals in the intervention group. Increase aftercare engagement, reduce readmissions
42 Tomita et al. (2012) USA, 2 New York City hospitals Critical time intervention (CTI) 150 total previously homeless men and women RCT At the end of the follow-up period, psychiatric re-hospitalization was significantly lower for the group assigned to CTI compared with the usual services group. Reducing readmission
43 Virgolesi et al. (2017) Italy, 3 hospitals in Rome Nursing discharge programme (a short-term nursing discharge programme with follow-up phone calls 7–10 days) 135 patients Prospective correlational design The interpersonal and educational nursing intervention improves adherence to a treatment plan. Medication adherence and patient satisfaction
44 Walker et al. (2000) UK, 3 wards (2 control) Discharge co-ordinators 343, 119 intervention, 224 control Controlled cohort study No differences in outcomes (readmission, LoS, mental health status, satisfaction). More satisfaction for those without intervention Improve communication between primary and secondary care
45 Zheng and Arthur (2005) China, 1 large hospital in Beijing Family education 101 patients (schizophrenia) RCT pre-test, post-test Significant improvement in knowledge about Schizophrenia in the experimental group. Significant difference in symptom scores and functioning at 9 months after discharge.

Knowledge about condition and rehospitalisation.

There is a need for culturally sensitive family treatments offered by nurses