At a press conference to release recommendations ensuring continuity of
care for patients with serious mental illness are (from left) Linda Rosenberg,
M.S.W., Joseph Parks, M.D., and Liz Carignan.
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
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
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
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
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
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
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
"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>.