The inpatient to outpatient transition: How to prevent gaps in mental healthcare

Nationwide, the number of patients needing emergency psychiatric care has been increasing. From 2005 to 2014, the total number of hospital stays for mental health/substance use conditions rose 12.2 percent in the United States, according to the most recent data from the Healthcare Cost and Utilization Project.

However, treatment for acute mental health issues does not end after the inpatient stay is complete. That's why ensuring continuous care is vital to prevent relapse or re-hospitalization. Many stakeholders in a patient's treatment journey can play a pivotal role to ensure patients don't experience gaps in care after discharge.

Here's what health system leaders and healthcare providers need to know to support the patient transition from inpatient to outpatient care.

In general, once a patient is discharged from an inpatient psychiatric unit, an outpatient provider takes over the patient's care, according to Dr. Megan Schabbing, medical director of psychiatric emergency services at OhioHealth Riverside Methodist Hospital in Columbus, Ohio.

Where the patient lives can dictate where a person will seek outpatient help.

“If the person lives in another state, a care manager or therapist may coordinate care by contacting providers in network with the person's insurance plan or payment source and assisting the person in scheduling services," said Jennifer McClendon, a licensed professional and clinical alcohol and drug counselor in New Jersey.

Typically, the inpatient facility will provide the patient with a two-week supply or 30-day supply of medication and/or a refill prescription. The inpatient hospital also usually schedules an appointment with an outpatient provider and gives the patient a list of support groups.

Shifting to an outpatient setting means some people may not have enough support to ensure they adhere to appointments or receive and take medications in a timely fashion. That can be where gaps arise.

Inpatient facilities typically do not follow up after discharging a patient, said Myisha Jackson, a provisional licensed professional counselor based in Louisiana.

Patients who seek outpatient care outside of the inpatient provider's medical system may experience gaps, too.

Jackson said that working at a facility with inpatient and outpatient care helped make the transition smoother. "Most of our patients that were inpatient came back for outpatient treatment," she said. "I was able to build a rapport with them while they were inpatient, so they knew what to expect from the outpatient care."

One of the biggest challenges in the transition from inpatient to outpatient care can be medication management.

Arturo Olivarez, a director of pharmacy for Cardinal Health, works in an outpatient clinic that's part of Rio Grande State Center, a Texas state hospital that specializes in mental healthcare. He said he often encounters a communication disconnect between outside, discharging inpatient behavioral health facilities in the surrounding region and their outpatient clinic, creating issues for the patient.

“By the time our clinic receives the new patient's referral information from an external discharging facility, often the patient has already depleted his or her supply of medication and is exhibiting moderate to severe signs of their mental health disorder," he added.

There are treatment protocols that can help address these challenges. A team-based treatment model called Assertive Community Treatment (ACT) can address medication management, therapy, social support, housing and employment. It has improved outcomes for people with severe mental illness who are most at-risk of psychiatric crisis, hospitalization and involvement in the criminal justice system. ACT can be used after an inpatient stay or in place of it.

Intensive Outpatient Programs (known as IOPs) or Adult Partial Hospitalization Program (known as APHPs) can also help to bridge the gap from inpatient to outpatient treatment. Transition clinics provide another method of transitional care for people who have no outpatient mental health provider.

In addition to implementing treatment protocols, the four experts offered specific steps for health system leaders and healthcare providers to help prevent or remedy gaps in care.

Automate medication management. Instead of struggling to obtain or remember to take pills, administering medication via a transdermal patch can be useful for patients, Jackson said.

A home health nurse may be also provided to ensure medication is taken, while some clinics give patients the option to use an app or wearable device to help them stay on track.

Remove the red tape. If timely patient record release procedures aren't in place, patients may not refill or take their medication on time and can miss therapy appointments. “Without the release of patient records, the outpatient clinic is in a difficult position to continue behavioral therapy," Olivarez pointed out.

Teach patients about the benefits of care. Patient buy-in is also important to prevent gaps, Olivarez noted. “We experience many patient 'no shows' because patients simply believe they do not need additional or on-going behavioral health interventions," Olivarez added.

Assign an advocate. Patients with lower functioning should have a power of attorney—someone who can make decisions on their behalf. “Their power of attorney could make sure they are being compliant with their medications and appointments," Jackson said. Inpatient facilities typically can tell if a person should have such an advocate, which can help promote continuous care. When protocols are instilled, it should account for assigning a liaison in these types of cases.

Call in help. While medical professionals can institute protocols to ensure continuity of care, Jackson said a person's support system is integral as well. “Family members and caregivers should be working with the mental health professional as well," she added.

Better patient support, whether it be from a social worker, sibling, or spouse, is vital to avoid gaps in care, Olivarez explained. Having someone who can help a patient who is too ill to manage his or her own treatment is imperative.

While the shortage of mental healthcare providers remains, there are promising developments in the coordination of care. Medication management programs with dedicated transition coordinators have been shown to decrease future hospital stays and ensure patients are adhering to prescriptions, while technology like telepsychiatry is gaining traction.

Olivarez is encouraged by these new developments yet noted that more still needs to be done. Because as he said, "the same attention paid to transitioning a patient from any other type of inpatient stay is needed with a patient experiencing mental health issues, too."