Lessons Learned from Implementing a Pilot RCT of Transitional Care Model for Individuals with Serious Mental Illness

Solomon, Phyllis; Hanrahan, Nancy P.; Hurford, Matthew O.; DeCesaris, Marissa; Josey, LaKeetra

doi:10.1016/j.apnu.2014.03.005

Cited by 14 publications

(10 citation statements)

References 22 publications

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“…In response to this, further care models have incorporated a ‘navigator’ role. While navigators or care coordinators are generally implemented to negotiate the boundaries between health, social care, education, and housing sectors, this role can be just as important for helping people with SMI negotiate boundaries within heath care, between physical and mental health services, or between primary and secondary care [132934354154]. …”

Section: Resultsmentioning

confidence: 99%

Integrated Care to Address the Physical Health Needs of People with Severe Mental Illness: A Mapping Review of the Recent Evidence on Barriers, Facilitators and Evaluations

Rodgers

Dalton

Harden

et al. 2018

International Journal of Integrated Care

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People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests this is due to a combination of clinical risk factors, socioeconomic factors, and health system factors, notably a lack of integration when care is required across service settings.Several recent reports have looked at ways to better integrate physical and mental health care for people with severe mental illness (SMI). We built on these by conducting a mapping review that looked for the most recent evidence and service models in this area. This involved searching the published literature and speaking to people involved in providing or using current services.Few of the identified service models were described adequately and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge. Efforts to improve the physical health care of people with SMI should empower staff and service users and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication among professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and greater awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered.

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Section: Resultsmentioning

confidence: 99%

Integrated Care to Address the Physical Health Needs of People with Severe Mental Illness: A Mapping Review of the Recent Evidence on Barriers, Facilitators and Evaluations

Rodgers

Dalton

Harden

et al. 2018

International Journal of Integrated Care

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“…By contrast, a US evaluation of a transitional care ('TCare') model for people with SMI being discharged from hospital to community care employed a psychiatric nurse practitioner (trained in medical and psychiatric assessment/treatment/ prescribing) as the navigator. 64 The intervention consisted of 10 components: (1) co-ordination of care by a psychiatric nurse; (2) a plan developed prior to hospital discharge; (3) home visits from the nurse for approximately 90 days post-hospital discharge and available 7 days a week; (4) co-ordination with physicians in the community, including accompanying service users on visits; (5) inclusive focus on health needs of the service user; (6) involvement of both service user and family in care through education and support; (7) early detection and quick response to health-care risks and symptoms; (8) service user, family caregiver and providers functioning as a team; (9) collaboration of nurse and physician; and (10) information sharing among all team members. Interestingly, this evaluation noted difficulties in engaging mental health case managers with the TCare programme.…”

Section: Navigators (15 Studies)mentioning

confidence: 99%

Integrated care to address the physical health needs of people with severe mental illness: a rapid review

Rodgers

Dalton

Harden

et al. 2016

Health Serv Deliv Res

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BackgroundPeople with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests that this discrepancy is driven by a combination of clinical risk factors, socioeconomic factors and health system factors.Objective(s)To explore current service provision and map the recent evidence on models of integrated care addressing the physical health needs of people with severe mental illness (SMI) primarily within the mental health service setting. The research was designed as a rapid review of published evidence from 2013–15, including an update of a comprehensive 2013 review, together with further grey literature and insights from an expert advisory group.SynthesisWe conducted a narrative synthesis, using a guiding framework based on nine previously identified factors considered to be facilitators of good integrated care for people with mental health problems, supplemented by additional issues emerging from the evidence. Descriptive data were used to identify existing models, perceived facilitators and barriers to their implementation, and any areas for further research.Findings and discussionThe synthesis incorporated 45 publications describing 36 separate approaches to integrated care, along with further information from the advisory group. Most service models were multicomponent programmes incorporating two or more of the nine factors: (1) information sharing systems; (2) shared protocols; (3) joint funding/commissioning; (4) colocated services; (5) multidisciplinary teams; (6) liaison services; (7) navigators; (8) research; and (9) reduction of stigma. Few of the identified examples were described in detail and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge from the evidence. Efforts to improve the physical health care of people with SMI should empower people (staff and service users) and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication between professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered.Limitations and future workThe literature identified in the rapid review was limited in volume and often lacked the depth of description necessary to acquire new insights. All members of our advisory group were based in England, so this report has limited information on the NHS contexts specific to Scotland, Wales and Northern Ireland. A conventional systematic review of this topic would not appear to be appropriate in the immediate future, although a more interpretivist approach to exploring this literature might be feasible. Wherever possible, future evaluations should involve service users and be clear about which outcomes, facilitators and barriers are likely to be context-specific and which might be generalisable.FundingThe research reported here was commissioned and funded by the Health Services and Delivery Research programme as part of a series of evidence syntheses under project number 13/05/11. For more information visitwww.nets.nihr.ac.uk/projects/hsdr/130511.

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“…Initial data analysis provided insights into the basic trends on mental health patients and initial distributions for percent of agents flowing over time around the pathways of Figure 5 as a function of health status (GAF score) and social attributes. We also verified parameters using research on the SMI population such as Folsom et al [27], Brown et al [28], Hanrahan et al [29,30] . Using all this data, we analyzed the overall sample population and then focused on populations with similar disease severities (earlier Quadrants I -IV).…”

Section: Calibration and Model Validationmentioning

confidence: 77%

A systems approach to healthcare: Agent-based modeling, community mental health, and population well-being

Silverman

Hanrahan

Bharathy

et al. 2015

Artificial Intelligence in Medicine

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PurposeExplore whether agent-based modeling and simulation can help healthcare administrators discover interventions that increase population wellness and quality of care while, simultaneously, decreasing costs. Since important dynamics often lie in the social determinants outside the health facilities that provide services, this study thus models the problem at three levels (individuals, organizations, and society). MethodsThe study explores the utility of translating an existing (prize winning) software for modeling complex societal systems and agent's daily life activities (like a Sim City style of software), into a desired decision support system. A case study tests if the 3 levels of system modeling approach is feasible, valid, and useful. The case study involves an urban population with serious mental health and Philadelphia's Medicaid population (n = 527,056), in particular. ResultsSection 3 explains the models using data from the case study and thereby establishes feasibility of the approach for modeling a real system. The models were trained and tuned using national epidemiologic datasets and various domain expert inputs. To avoid co-mingling of training and testing data, the simulations were then run and compared (Section 4.1) to an analysis of 250,000 Philadelphia patient hospital admissions for the year 2010 in terms of re-hospitalization rate, number of doctor visits, and days in hospital. Based on the Student t-test, deviations between simulated vs. real world outcomes are not statistically significant. Validity is thus established for the 2008-2010 timeframe. We computed models of various types of interventions that were ineffective as well as 4 categories of interventions (e.g., reduced per-nurse caseload, increased check-ins and stays, etc.) that result in improvement in well-being and cost. ConclusionsThe 3 level approach appears to be useful to help health administrators sort through system complexities to find effective interventions at lower costs. AbstractPurpose: Explore whether agent-based modeling and simulation can help healthcare administrators discover interventions that increase population wellness and quality of care while, simultaneously, decreasing costs. Since important dynamics often lie in the social determinants outside the health facilities that provide services, this study thus models the problem at three levels (individuals, organizations, and society). Methods:The study explores the utility of translating an existing (prize winning) software for modeling complex societal systems and agent's daily life activities (like a Sim City style of software), into a desired decision support system. A case study tests if the 3 levels of system modeling approach is feasible, valid, and useful. The case study involves an urban population with serious mental health and Philadelphia's Medicaid population (n=527,056), in particular.Results: Section 3 explains the models using data from the case study and thereby establishes feasibility of the approach for modeling a real system. ...

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Lessons Learned from Implementing a Pilot RCT of Transitional Care Model for Individuals with Serious Mental Illness

Cited by 14 publications

References 22 publications

Integrated Care to Address the Physical Health Needs of People with Severe Mental Illness: A Mapping Review of the Recent Evidence on Barriers, Facilitators and Evaluations

Integrated Care to Address the Physical Health Needs of People with Severe Mental Illness: A Mapping Review of the Recent Evidence on Barriers, Facilitators and Evaluations

Integrated care to address the physical health needs of people with severe mental illness: a rapid review

A systems approach to healthcare: Agent-based modeling, community mental health, and population well-being

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