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

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

The study, conducted by a team of researchers at the University of Washington, focuses on the millions of hospitalizations each year that are caused by a traumatic injury. Many of those patients return to the hospital after discharge because of mental health issues tied to that trauma, with as many as 40% dealing with post-traumatic stress disorder (PTSD).

Improving the care coordination process after a hospital visit is one of the top innovation challenges facing health systems. So many care gaps are created when the patient leaves the hospital and heads either to a rehab or SNF facility or back home. Doctor’s orders and prescriptions are forgotten or even ignored, care plans are interrupted or dropped altogether, and recovery is delayed, often leading to negative clinical outcomes, including rehospitalization.

The study, led by Laura Prater, PhD, MPH, MHA, an assistant professor at The Ohio State University of Public Health, and published in the Annals of Surgery, tracked 171 patients who were treated at a University of Washington trauma center. Half were treated via the traditional process, and half were involved 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% of patients undergoing traditional care were rehospitalized within three to six months, compared to 16% of patients involved in the mental health intervention program. After 12 to 15 months, 31% of the traditional-care patients were back in the hospital, compared to 17% of those in the intervention program.

“Being able to manage PTSD and other mental health concerns early on and receive regular follow-up support can prevent adverse long-term health problems and increase 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 included digital health tools aimed at offering on-demand services to those patients.

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

The study reinforces research done earlier this year at Vanderbilt University, which used a National Institutes of Health grant to study new methods of addressing post-intensive care syndrome (PICS), which can affect as many as 80% of patients discharged from a hospital after an ICU stay. That study found that a reconfigured post-discharge care management and coordination program focused on virtual care could reduce rehospitalizations and improve clinical outcomes.

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

“Being in the emergency department is traumatic in its own right, plus returning to the scene where you first received care following an injury or assault is not ideal,” Prater said in the press release. “Managing trauma and the mental health fallout from that trauma is best done at home, where you’re in a safe location.” 

Eric Wicklund is the associate content manager and senior editor for Innovation, Technology, Telehealth, Supply Chain and Pharma for HealthLeaders.


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