WN: Program Eyes Mental Health Transition Help

NYAPRS Note: The following piece describes success hospital to community supports in Canada that include peer bridgers, a model first developed by NYAPRS in 1994 that has been demonstrated to help reduce returns to NYS psychiatric hospitals in 2008 by 72% (OMH funded) and reduced the number of people who were readmitted in a 6 month period in 2012 to downstate Medicaid hospitals as well as hospital days by about 50% (funded by OptumHealth). Optum has adapted this model in other states with Tennessee and Wisconsin peer link programs reducing recidivism by 73% and 44% respectively.Peer bridger services are just one of many peer service innovations that are expected to be a major part of the benefit package of many states' integrated, managed care plans and health home initiatives.

Program Eyes Mental Health Transition Help

By Paul Mayne Western News April 11, 2013

The transition from hospital to community can be challenging for those diagnosed with a mental illness. Research shows the first days and weeks following psychiatric discharge are particularly high-risk periods for relapse, with 43 per cent of suicides occurring within the first month post-discharge, and another 40 per cent of patients being readmitted to hospital during that same time.

"If we do a better job, this shouldn't happen," said Western professor Cheryl Forchuk.

The associate director of Nursing Research is looking to bridge that gap between hospital and community by leading a new Ontario-wide approach for discharging mental-health clients from hospitals.

"Think about what it means for someone who has a mental-health problem to leave hospital," said Forchuk, assistant director of Mental Health/Health Outcomes Research at Lawson Health Research Institute. "What we have found, over and over again, is that this is a lonely experience. It is a time when they have the highest need of support. But one of the problems in our system is often there is a problem with continuity of support from the health system to the community support system."

The Transitional Discharge Model (TDM) is designed to provide seamless support as clients make this transition. TDM ensures hospital staff members continue to provide care until the client is connected with a community care provider. It also partners discharged clients with a peer who has successfully integrated into the community after a psychiatric diagnosis.

In an earlier pilot study, Forchuk implemented this project in 13 wards at four regional hospitals while a matched 13 wards provided usual care. Results showed the length of stay was reduced by an average of 116 days per client, amounting to more than $12 million worth of freed bed space and $4,400 less hospital and emergency room services, per person, in the year after discharge.

The TDM is now being rolled out to nine Ontario hospitals in Toronto, Ottawa, Whitby, Kingston, Thunder Bay, Hamilton and London.

The project is funded by a $1.5 million grant through the Council of Academic Hospitals of Ontario's Adopting Research to Improve Care program. Forchuk said her team hopes to continue to improve patient outcomes and reduce the strain on hospital resources, while strengthening the working relationships between hospitals and community support groups.

"This is a made-in-Ontario solution that has already been developed, tested and proven. We want to see this implemented across the province as the best practice to provide support over the discharge process," she said.

Forchuk emphasized the importance of speaking to the patients themselves, those who have dealt first-hand with the process, in order to understand what needs to be done to show improvement in a system with obvious gaps.

"The consistent picture that came up in our discussions was a bridge, and that bridge was people," she said. "The patients need two kinds of support. They form that relationship in hospital and are comfortable with that, but we can't let go until they have a strong relationship in the community with a provider. We want to overlap to provide strength to the bridge to get them through that discharge process."

Forchuk said in London's three mental health wards alone, more than 800 patients are discharged each year. Imagine what the numbers are province-wide, she suggested.

"This has the potential to help thousands of people across the province who are leaving psychiatric wards and returning home," Forchuk said. "This is not always easy because it challenges people in many ways; it challenges the hospitals in how they see their roles with a peer support organization.

"But if we offer a complete partnership - the client, the peer supporter, the community staff and the hospital staff all staying in until