Action Sought to Close Gap in Hospital, Outpatient Care

It is a tragic situation that happens too often—a patient with schizophrenia is discharged from the hospital, and for a multitude of reasons he or she never reaches a critical first outpatient appointment and ends up back in the hospital, homeless, or in jail.

The reasons for this schism in care are complicated and involve faulty communication between inpatient and outpatient mental health staff, ineffective administrative policies, and poor funding, among other factors, according to a consensus statement issued by the National Council for Community Behavioral Healthcare (NCCBH) in March.

NCCBH is a nonprofit association comprised of 1,300 behavioral health care organizations throughout the country.

In December 2006, an expert panel convened by NCCBH met to develop recommendations for implementing a system-wide initiative to improve the continuity of care between inpatient and outpatient settings to ensure that patients with serious mental illness are not lost to care after being discharged from hospitals.

The panel developed a consensus statement and a number of recommendations for health care systems, clinic and hospital administrators, psychiatrists and mental health professionals, consumers, and families to improve continuity of care (see information at end of article).

According to the statement, as many as half of patients with serious mental illness who are discharged from hospitals do not appear for their initial appointment to the outpatient mental health clinician to whom they were referred.

The findings come from research funded by Janssen Pharmaceuticals and published in 1997 in the Archives of General Psychiatry.

Janssen also funded the development of the consensus statement and recommendations.

In many cases, “people with serious mental illness, especially those with schizophrenia, aren't staying in treatment” once discharged from psychiatric hospitals, said NCCBH President and CEO Linda Rosenberg, M.S.W., at a press conference to announce the consensus statement at the NCCBH annual conference in Las Vegas.

The period between hospital discharge and first outpatient contact is often fraught with difficulties for patients with serious mental illness. For instance, upon discharge, they are often placed on long waiting lists for community-based services and end up having their intake and clinical appointments scheduled weeks apart.

Said Rosenberg, “Sometimes after patients are discharged, they must wait for weeks for an appointment with a psychiatrist, and they wind up coming into the emergency room to get medications” because they are discharged with an insufficient supply of medications and relapse in the intervening period.

In addition, inconsistent or incomplete medical records may hamper patients' transfer from one facility to another, complicating treatment and compromising their mental health.

The human costs for those who go untreated are many, Rosenberg noted: symptom exacerbation resulting in lost vocational and educational opportunities, social isolation, and possible criminal-justice involvement.

In the case of Liz Carignan, a patient from Maine with schizophrenia who spoke at the press conference, the problems associated with the transfer from inpatient and outpatient settings has caused her family a great deal of hardship—not just due to her own illness, but that of her sons, who also have serious mental illness.

After being discharged from a lengthy hospitalization, there was no coordination between inpatient and outpatient providers and “a lack of continuity of care around my medications and therapy, which prolonged my recovery unnecessarily,” she stated.

Her sons also experienced more than their share of difficulties when it came to receiving consistent care across inpatient and outpatient settings. For instance, her oldest son has experienced at least 25 hospitalizations, she said. “In the past 12 years, his medication history has never been placed on one record,” Carignan remarked. Instead, physicians prescribed medications that he had tried before without success “over and over.”

In the months before his current hospitalization, she said, her son lost four jobs, had three car accidents, and was arrested and homeless because he had not been referred to outpatient treatment and had not been taking medications.

Soon after a serious suicide attempt by her younger son, she was shocked to find him on her front steps “with double pneumonia from aspiration and off his psychiatric medications,” she told meeting attendees. He'd been discharged against medical advice and was “sick, depressed, and confused.. .sometimes I cry when I think that he didn't have the opportunity to stabilize in a safe, secure place” because he was released without a referral for psychiatric treatment.

According to Rosenberg and fellow panelist Joseph Parks, M.D., medical director of the Missouri Department of Mental Health, hospitals and community-based mental health agencies need to collaborate more closely to ensure that people with serious mental illness make a smooth transition to outpatient care.

“Hospital administrators need to be comfortable communicating with community-clinic supervisors” and vice versa, Parks said.

Continuity of care is often disrupted when patients are discharged from an inpatient stay and must first see an intake officer who arranges for subsequent outpatient visits, he noted. The patient must then wait a certain period of time before going to see the outpatient provider and case manager.“ We can do better than this,” he noted.

Parks noted that one of the recommendations issued by NCCBH urges adoption of a “pull model” of mental health treatment, in which a community mental health professional meets with the soon-to-be-discharged inpatient to arrange for outpatient treatment and begin collaborating with the patient on a treatment plan. “It's much easier to go to an appointment with someone you already know, as opposed to someone you don't know,” he said.

Another strategy is to designate a case manager to bridge the gap between inpatient and outpatient settings, Parks said.

Rosenberg noted that under Medicaid, case managers are often reimbursed for serving as a link between inpatient and outpatient settings.

Psychiatrist Anand Pandya, M.D., one of the council members who helped develop the consensus statement and recommendations, told Psychiatric News that psychiatrists can do their part by implementing the recommendations where possible and advocating for the “pull model” of transitioning inpatients to outpatient settings.

Pandya represented the National Alliance on Mental Illness at the December 2006 meeting as one of the organization's vice presidents. He is also a clinical assistant professor of psychiatry at New York University School of Medicine and a member of APA's Scientific Program Committee.

Having outpatient clinicians proactively enter inpatient settings to meet with patients in anticipation of their discharge “creates better treatment plans and improves continuity of care,” he noted.

“The Consensus Statement on the Continuity of Medication Therapy for the Treatment of Schizophrenia and Other Serious Mental Illnesses” is posted at<www.nccbh.org>.