Table 1.
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 |