Innovation in the plan of care starts with access to mental health

Redesigning post-discharge care to include mental health resources can reduce readmissions and readmissions and improve recovery and clinical outcomes

Health system leaders are constantly looking for strategies to reduce readmissions. A new study says that redesigning post-discharge care to include mental health services, including through digital health and virtual channels, could cut that rate of return in half.

The study, conducted by a team of researchers from the University of Washington, focused on the millions of hospitalizations each year that are caused by traumatic injury. Many of these patients return to the hospital after discharge due to mental health problems related to this trauma, with around 40% dealing with post-traumatic stress disorder (PTSD).

Improving the care coordination process after a hospital visit is one of the main innovation challenges facing healthcare systems. So many gaps in care are created when the patient leaves the hospital and goes either to rehab or to an OC facility or back home. Physician orders and prescriptions are forgotten or even ignored, treatment plans are interrupted or dropped altogether, and recovery is delayed, often leading to negative clinical outcomes, including re-hospitalization.

The study, led by Laura Prater, PhD, MPH, MHA, assistant professor of public health at The Ohio State University, and published in Annals of Surgery, followed 171 patients who were treated at the University of Washington trauma center. Half were treated through the traditional process, and half were enrolled in a five-year, three-step program that included enhanced care specific to mental health needs during hospitalization and 24/7 access to mental health services after discharge.

According to the study, 27 percent of patients receiving traditional care were rehospitalized within three to six months, compared with 16 percent of patients enrolled in the mental health intervention program. After 12 to 15 months, 31 percent of patients in the conventional treatment were back in the hospital, compared with 17 percent of those in the intervention program.

“Being able to address PTSD and other mental health issues early and receive regular follow-up support can prevent adverse long-term health problems and enhance a survivor’s ability to live a productive, meaningful life,” Prater said in a press release issued by The Ohio State University.

The intervention program includes digital health tools aimed at offering services on demand to these patients.

“An immediate response to a text message or phone call to questions and concerns is potentially the most meaningful element of the intervention from the survivor’s perspective,” Prater said. “A lot of places use MyChart or some other form of messaging, but responses can be delayed and that’s problematic if someone feels overwhelmed. Having an instant connection helped patients and their families feel like they weren’t alone.”

The study supports research done earlier this year at Vanderbilt University, which used a grant from the National Institutes of Health to explore new methods of dealing with post-intensive care syndrome (PICS), which can affect up to 80 percent of patients discharged from a hospital after a stay in the intensive care unit. This study found that a reconfigured postdischarge care management and coordination program focused on virtual care can reduce readmissions and improve clinical outcomes.

Both studies point to a need to change the way hospitalized patients are treated after they leave hospital, with greater emphasis on the traumatic nature of hospital stays and improved access to mental health services to help patients recover. recover – mentally as well as physically – from their health concerns.

“Being in the emergency room is traumatic in itself, plus returning to the place where you first received care after an injury or assault is not ideal,” Prater said in the press release. “Managing trauma and the mental health consequences of that trauma is best done at home, where you are in a safe place.”